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<br />"'
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STA TE DEPAR;[MENTfJE:_HEAL TH,
<br />IT CERTIFIES THE BELOW TO BE A TRUE COPY OF AN ORIGINAL RECORD ON.FilEWlTII ri(/J,'$j[A TE
<br />DEPARTMENT OF HEAL TH, BUREAU OF VITAL STA TISTICS, WHICH IS THIf,-t:Ei;AL!!EP~lTiJR}O!flR
<br />
<br />:;;::;~ W~~,
<br />JUN 1 3 1994 2 0 0 7 0 8 4 2 7STAfliLEV; s. ~igOPER, gtkicr9#
<br />BUREIM/ OF VITAL STA~!STICS
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />1 DECEOENT - NAME
<br />
<br />FIRS"'!
<br />
<br />"
<br />
<br />STATE O~~~~~i,~Ifi~J~1~:;: rD~~ZC'O
<br />
<br />
<br />MIDDLE" lAST 2 SEX 3 DATE 0; DEAtH
<br />
<br />IMonth Oil't Yea.rl
<br />
<br />steadman
<br />
<br />
<br />Male
<br />UNDEFl1 YEAR UNDERl DAY
<br />5tJ MOS I DAYS 5< HOURS MINS
<br />I
<br />
<br />
<br />4 CITYANDSTATEOFBIFlTH IHnotlflU5A namecounfryJ
<br />
<br />: 7 SOCIAL SECuRTIY N MBER
<br />
<br />505-30-2935
<br />. 8b FACILITY. Name
<br />
<br />(ff nollnstrtutton. g/1I8 street ana numberj
<br />
<br />HOSPITAL D Inpahef'lt OTHER 0 ~l,Ir5lnq Home
<br />/A VJ ER Outpa_, D ~IO@~e
<br /> 0 OOA 0 Other 1~/fyl
<br /> ~ t;9UNTY nl=" nj:" iI. TIJ ~~"^-~'~' ,,'..~~'-'_.
<br /> .~--"""",,---,--._'-'" ~
<br />
<br />
<br />St.a Francis Medi('!;:'J 1 (,.p.,h~r
<br />- Be CITY. TOWN OllLOCATION OF DEATH
<br />---Grima IsIalld, --Nebraska
<br />g. RESIDENCE - STATE
<br />
<br />STREET AND NUMBER i1r<;<AnflI", C_I
<br />
<br />Nebraska
<br />
<br />68801
<br />
<br />
<br />NoD
<br />
<br />13 HAW; OF SPOUSE (n wffe give ttJiIIIJen name)
<br />
<br />e1cIISpecotyl ISoecotyl
<br />White American ':;~
<br />
<br />14a uSuAL OCCuPA nON (Gille kind 01 WQt'i Oof)e I1UfIf';g mcst ,..,.-.. t 4b KIND OF BU~ESS INDUSTRY
<br />
<br />OIworl<''''lIde/,.-t_NI '0,!..J'. CoWX/ Vl'df!O C
<br />- CMner ator (Technician - ompany
<br />
<br />;6 FATHER. NAME FIRST MIDDlE LAST .7 MOTHER
<br />
<br />Olar lene M. Cox
<br />
<br />James L.
<br />t 6 WAS DECEASEO Evm IN u.S. ARMED FORCES?
<br />(Yeti. r'\Q, 01' unk..1 '" yes. gl.....e war aIld da.le5 Of WVJC;$S!
<br />Yes Korean Conflict
<br />100 INFORMANT MAlUNG ADDRESS
<br />
<br />
<br />Cox
<br />1948 to
<br />1952
<br />
<br />CharI
<br />
<br />M
<br />
<br />1103 S. Eugene St.
<br />20 EMBALMER" SIGNATURE & LICENSE NO.
<br />
<br />Grand Island
<br />11' METHOD Of DISPOSITiON
<br />
<br />NE.
<br />lIb. DATE
<br />
<br />68801
<br />
<br />21< CEMETERY OR CREMATORY NAME
<br />
<br />Not Embalmed
<br />
<br />D a..,,,.. D Rem,,,.1 May 25, 1994
<br />
<br />Central NE. Cremation Service
<br />
<br />221>. FUNERAL HOIAE ADDRESS
<br />
<br />
<br />@cremoiEan 0 OorlallOfl
<br />
<br />11 d. CEMETERV OR CREMATORy LOCATION
<br />Gibbon, Nebraska
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />22. FUNERAL HOIAE - NAME
<br />
<br />3213 W. North Fran S
<br />23. IMMEDIATE CAU~
<br />PART"- ~ .
<br />
<br />1"b'!E TO, OR AS ACONSEOu -~o~rv.~(....f
<br />
<br />
<br />Inl&rval Mtween onset and dearh
<br />
<br />hUI-1;J
<br />
<br />Interval t>etween on&et and death
<br />
<br />Ibl
<br />DUE TO OR AS A CONSEQuENCE OF
<br />
<br />Inter.....al t:>etween onset ar)(j death
<br />
<br />1<1
<br />OTHER ~GNIFfCANT CONDITIONS - CooditIQns contribUting 10 tOe oeath oot r'IOt r~ated
<br />PART
<br />"
<br />
<br />;>l;a
<br />
<br />o AcC:ldent 0 Undeterl'mnecl
<br />o SUICide 0 j:Jenalng
<br />D HomICK1e InyeslIgoiltlQn
<br />
<br />I
<br />
<br />2Gb DATE OFlNJURY IMo. o..y, y,.) 26t HOUR OF INJURY
<br />
<br />
<br />WAS CASf Re;FERREO TO ME~CAl
<br />EXAMINER OR CORONER?
<br />Ves n No~
<br />
<br />
<br />M
<br />261, ~~~c;:.~~~.y tt=.larm, slreet. factory
<br />
<br />26g. LOCATION
<br />
<br />STREET OR R F:l NO
<br />
<br />CITY Ot=il'OWN
<br />
<br />STAlE
<br />
<br />26e INJURY AT WORK
<br />Vos 0 No 0
<br />
<br />
<br />la. DATE SIGNED IMo.. Day. Y'I
<br />
<br />281> TIME OF DEATH
<br />
<br />. ,..
<br />
<br />z>-
<br />E~~
<br />~U\<r
<br />If. g >-
<br />....~
<br />~>-z
<br /><r~O
<br />Zl~
<br />''''is'-'
<br />'-' 0
<br />
<br />M
<br />
<br />2Be PRONOUNC~D DEAD lMo O.y. y,
<br />
<br />2"". PRONOuNCED DEAD tHou!)
<br />
<br />M
<br />
<br />28e, On tne DaSI~ 01 8;r:amlnallOO <100 Of n~9-3non, In my opinion death occurred at
<br />the 111l"1E!, c;1ate and pI,iIce and due 10 tI"II!' ~~Sl stated
<br />
<br />o NO
<br />IT'ttIt101" Prlnt.1
<br />~/JU
<br />
<br />b WAS CCiNSENT GRANli:.D'i'
<br />DYES
<br />
<br />~
<br />
<br />32a, REGISTAAA
<br />
<br />
<br />J"j I ~ .. ,/
<br />
<br />/l,/ 1.:;"
<br />
<br />J2D, DAtE FllEO a'" qe:CISTRAR (Mo,. ~y. Yt.!
<br />
<br />JIAYS 11994
<br />
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