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<br /> ~-h ~ <br /> ~ ~ 10 n ~ t~...~ ~ <br /> r~ ~ m X =.., C") <br /> -n m Con ~ UJ <br /> ~ ~~ c: n ::I: ......... ~ C> -; c:> <br /> Z ....l:l., c: J;e> <br /> ~ (') X ~ '. = Z -1 N a <br />N -..... ~ C .'''-...! ':J <br /> ::c -l rr1 <br />\Sl ~ H'. rTl ,I- --i c:> <br />\Sl )- m (;-') t>.""- -< C ~ <br />-...J t-) ~\ n c.n (:) (""1 w 0 -,., 0 <br />, - '" :i:: ~ <br />\Sl -T] " - <br /><0 , tJ ...".- -J ::2 <br />, CJ :x: P-l <br />W ~ \)J ~ m ~' ::n J> rr_.t C) ~ <br />->. <br /> '1 ~ P1 :3 r ;x:J <br />CJl ~ <:::> r l:~ CD <br /> {'~ ~ c;n UJ l <br /> ~ ~ (D ;:><;; C..0 <br /> ~' ,,j >- ~ <br /> ~ < t-a ---- '-' <br /> 1-& C/l CJ1 ~ <br /> lJJ ~ C:f) <br />--- - --- ------- <br /> <br /> <br /> <br />LINCOLN, NEBRASKA <br /> <br />WHEN THS COPYCARRIE'S THE. RAISED SEAL OF niE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEA( "CERTlFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE~WlTH <br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA TISTl~rlOt#/jiIfBgt IS <br /> <br /> <br />~i:;i:::ORY;;;7~:15 ~~~ <br /> <br />HEAL TH AND iiJ!~ SEIlVlces_.~~ <br />:}_ ':'~.J_ ~_~~~.~:~.~,-:_~~~~_!! <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SER-\'l~Itl.Am:E~SuPPoRT <br />VITAL STATISTICS -- - --- 'C""'~_ c -:-"'"'- <br />CERTIFICATE OF DEATH <br /> <br />L DECEDENT. NAME <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />LAST <br /> <br />2_SEX <br /> <br /> <br />2 <br /> <br />Paul <br />4_ CITY AND STATE OF 61RTH iN net In USA. n.meCO""'rrl <br /> <br />Benjamin Johnson Male <br />5._ AGE - L..I 6;rthday UNDER 1 YEAR UNDeR 1 DAY <br />IY,,_I 5b_ MOS_ DAYS 5e_ HOURS - MINS_ <br />66 <br /> <br />2004 <br /> <br />Ware, Iowa <br />7_ SOCIAL SECURTIY NUMSER <br /> <br />1937 <br /> <br />s._ PLACE OF DEATH <br /> <br />478-36-3844 <br /> <br />HO~~!~ D Inpatient <br />D ER OUlpa1ienl <br />D DOA <br /> <br />orH~_~: 0 NurSing Home <br />IX] Residence <br />D Other (Sp8CltVI <br /> <br />Sb. FACIL.ITY. Name (Hrlot institution. giVtJ$trul and numbBr) <br /> <br />4204 Nevada <br /> <br />10. RACE: -Ie.g.. White, Black. AmeriCan India,n, <br />eto.IISpeellyl Wh i t e <br /> <br />14,,- USUAL OCCUPATION {GIV."indo{_"d(Jr>.dllfingmos' <br />Of working /iiB. 8V8n II retired! <br />Self-em 10 ed <br />16_ FATHER - NAME FIRST MIDDLE <br /> <br />American <br /> <br /> <br />(Incivding Zip C_I <br /> <br />90_ INSIDE CITY LIMITS <br /> <br />~ <br />~ <br /> <br />Be_ CITY_ TOWN OR LOCATION OF DEATH <br /> <br /><;rand :I:sl,a:Q.Q. <br />9a. RESIDENCE. STATE <br /> <br />Nebraska <br /> <br /> <br />11. ANCESTRY te.g,. Itall$". Me,Kican, German,8tcl <br />ISpec,lyj <br /> <br />68803 y..1KJ NO 0 <br />13. NAME OF SPOUSE (If wi fl}. givBmaiden rtam6! <br /> <br />Sally Parde <br /> <br />Walter <br />1 S_ WAS DECEASED EVER IN U_S. ARMED FORCES? <br />(Y85. f1(J. or unk.l lit yes. give war and dates of $@1'vt(:(l'S) <br />YeS 1957 thru 1965 <br />191>_ INFORMANT MAILING ADDReSS <br /> <br />B. <br /> <br />Beatrice <br /> <br />Eaton <br /> <br />~ <br />i'--- <br />co, <br />\) <br />~ <br />~ <br /> <br />UJ <br />-0 <br />~ <br />CJ <br />'5 <br />~ <br /> <br />Service <br />LAST <br /> <br />15. EDUCA TIQI'II (Specify only highe5t grade completed) <br />Elementary or Secondary lQ-l21 College 11-4 or 5"\ <br />12 <br />MIDDLE MAIDEN SURNAME <br /> <br />Sally Johnson <br />ISTREIIT OR R-F_D_ NO" CITY OR TOWN_ STATE_ ZIP) <br /> <br />Livingston,...Sondermann F .H. Dcrom..~ o Don.lleo <br />22b_ FUNeRAL HOME ADDRESS ISTREET OR R.F_D_ NO" CITY OR TOWN. STATE. ZIP) <br /> <br />Pocahontas <br /> <br />Iowa <br /> <br /> <br />o <br />::?:" <br />llJ <br />::E <br />U) <br />0:; <br />llJ <br />o <br />0:; <br />o <br />U <br />1IJ <br />c:: <br /> <br /> <br />68803 <br /> <br />[]g Burial D Removal <br /> <br /> <br />21e_ CeMETERY OR CREMATORY NAME <br /> <br />210_ METHOD OF DISPOSITION 2lb_ DATE <br /> <br />Summit Hill Cemeter <br />CITY OR TOWN STATe <br /> <br />601 North Webb Road, Grand Island, NE 68803-4050 <br />, 23_ IMMEDIATE CAUSE IENTER ONLY ONE CAUSe PeR LINE FOR Ial_ fbl. AND ICII <br />Y1 l1'1I\. H- cJ ~ 5 }t.I ..1 s L'1 vf4 HOlM t:L <br /> <br />ENCEOF L-lL.1 C? lIU..' c.. L"l14A p kOUfrh'c- Le/..l k.PINf~ <br /> <br />Interval between onssl and aealn <br /> <br />ART <br />I <br /> <br /> <br />.:3 Moo::::.. <br /> <br />Interval between onsel and death <br /> <br />'3 ~ <br /> <br />Interval between onSet and death <br /> <br />(el <br />PART OTHER SIGNIFICANT CONOITIONS - C9I'<l~on. eolllributiog to tho do.m bul not related <br /> <br />II n. C}vLL.. <br /> <br />26._ <br />0 Accident 0 Undetermined <br />0 Sl,Iicide 0 Pending <br />0 Homicide Investigalioo <br /> <br />2fib_ DATE OF INJURY {Moo. fI'Y- Yr_1 26e_ HOUR OF INJURY <br /> <br /> <br />26g. LOCATION <br /> <br />STREET OR R_Fn NO. <br /> <br />CITY OR TOWN <br /> <br />STAT" <br /> <br />260_ INJURY AT WOR~ <br />YosD NoD <br /> <br />270. DATE OF OEATH (Mo._ DBy_ Yr) <br /> <br />1-4 -oLf <br /> <br />2B._ DATE SIGNED (Mo__ Day Yr-! <br /> <br />2Bb_ TIME OF DEATH <br /> <br /> <br />z>- <br />~:S," <br />l!l "'>-u g <br />e. TIME OF DEATH J it I: >- 2Be_ PRONOUNCED DeAD (Mo__ Day. Yr) <br /> <br />\ : 2r\ II ~ ~ is <br />.J-J M B~':: <br />d To the best of my knOWIIit~ge e urrcd at the timlll. date and place and due to the t2 ~ a 288. On the bas. is of examination and 10. r InVe$tisa. tiO. n." in my opinion death occurred <br /> at <br />causelsl Slated . .#./ ~ . . L /7.i J" Jtt1V1 u 5 ...... the time, date and place and due to the cau5efSj stated. <br /> <br />lSlgnatureandTltlel.... ~~_ __ _ r {$ignaturean.d'ritlej" 'tI <br />_ DID TOBACCO USE CONTRI6UTE TO TI:'-e DEATH7 . HAS ORGAN OR TISSUE DONATION 6EEN CONSIOERED? )i'fii---WAS CONSENT GAANTED?-- - ------- <br /> <br />o YES ~ NO D UN~NOWN 0 YES ~ NO 0 YES IE!' NO <br /> <br />M <br /> <br />7b_ DATE SIGNEO (Mo__ DBy_ Yr) <br /> <br />1 - to -0'-1 <br /> <br />2Bd_ PRONOUNCED DEAD tHourl <br /> <br />M <br /> <br /> <br />IS &.Cj'd. AlE Ur? i23 <br />32b_ DATE FILED 6Y REGI31\'NtMo-C D"8Y'2004 <br />