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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE DEPARTMENT'tJF HEAL TH,
<br />IT CERTIFIES THE BELOW TO BE A TRUE COPY OF AN ORIGINAL RECORD ON FII;..!.J/YITHTHE STA TE
<br />DEPARTMENT OF HEAL TH, BUREAU OF VITAL STA TlSTICS, WHICH IS THE L~l DEPO~'FOR
<br />VITAL RECORDS. j~;~ 0 '-'-- _ #ck':;:';~
<br />
<br />DA TE OF ISSUANCE iif -_ . '-- --. ~
<br />99 >;;; .. STAN. EY S_ CfJ(jP~~
<br />L~~~.:;BR~SK; 20080297 2 NEBRA~~;"~
<br />
<br />
<br />- _~~~7.~'
<br />-..
<br />
<br />STATE OF NEBRASKA - DEPARTMENT o~nJol
<br />BUREAU OF VITAL STATISTICS -.. .,.
<br />CERTIFICATE OF DEATH
<br />
<br />. :;-~~
<br />
<br />:........ I"
<br />
<br />1 OECEOEN1. NA"E
<br />
<br />FIRST
<br />
<br />"'DOLE LAST 2 SEX IMonth Oar. Yearj
<br />Sheridan Hanun, Sr. Male 1995
<br />5a AOE;= last Birtnd.ay UNDER 1 YEAR UNDER T DAy
<br />(VrS,1 51>. "OS DAYS 5<. HOURS' MINS
<br /> 64 27 1 1
<br />
<br />Sa. PLACE OF DEATH
<br />HOSPIl'AL'
<br />
<br />
<br />Philip
<br />
<br />4 CIT'YANDSTAtEOF8IRTH f/(not;,U.S,A..tkJTneCOUntry/
<br />
<br />Sarver, Pennsylvania
<br />
<br />- 'j" . SociAL SE URTIY NU"'BeR
<br />
<br />: Bb. F ACIUTY - Name .
<br />
<br />{It not ilJstrtutJon, gWs sltrMt and numtJtH}
<br />
<br />B. Inpatief1l OTHER 0 Nut$lng Home
<br />D ER~", 0 ResJoor'tCe'
<br />0 OOA ....D QIno, l$pee'fy,
<br />
<br />208 26 1701
<br />
<br />I,. Yi\J1edical Center, 2201 N. Broadwell
<br />.8<' tiT;; lOWNQR LOCIoTION.Qf DEATH 6d INSIOE CITY LI...ITS Be COUNTY Of OlOATH
<br />ii
<br />
<br />GJand,Is~and, N~braska
<br />ge RESIDENCE. ST toTE
<br />
<br />
<br />
<br />9<1. STREET AND NUMllER 1'''''''''''''9 Z", C_I
<br />
<br />ge INSIDE CITY LIMITS
<br />
<br />Nebraska Wood River
<br />10. RACE.'/'.9-.WhiIo,Black.A",..,eO/'hdoan 1,. ANCESTRYI.g _....,"'....Gonnon.etcl 12. rn "'ARRlED
<br />OlC'ISQocolyl White ISQocoly, NEVER
<br />French, German " R
<br />_ 14. USU-'lOCCUPATION 1e>-_at_r1CntJ<iJnngtrJ()$/ 14b KIND OF BUSINESS INDUSTRY
<br />
<br />~ ati?6ii~~Officer, Retired
<br />
<br />i 16. FATHER. NJlMf FIlST ....DDLE
<br />
<br />i (Dec.); Harry Elmer
<br />;;'i'8 WAS DECb\SED EVER IN U.S. _ED FORCES?
<br />! ~es"-I "~retnam~nm'o
<br />~ 1.... INFOAM.ANT
<br />i
<br />
<br />Yes ~ No 0
<br />
<br />B~veFly Alice 'Doutt
<br />
<br />15 EDUCATION, ISpec,ty ""'y h'9""tllJf- <""""",,",I.~":
<br />
<br />Elementary .. SocoOd.ry 10. 121 College /14 0' ,. I
<br />12th
<br />
<br />"'DOL E MAIDEN SURNAME
<br />
<br />Cora
<br />
<br />M.
<br />
<br />M
<br />
<br />
<br />MAIl.ING ADDRESS
<br />
<br />-"7!31!7Peverly A.
<br />ISTREET OR RF 0 NO.. CITY OR TOWN. ST A IE. ZlPI
<br />
<br />',11'.
<br />
<br />
<br />1,.11..
<br />
<br />~1IuNlI DRei.ov., Nov 6,1995, Greenwood MemOT:ial .Par.k
<br />21<1' CEMETERY OR CREMATORY LOCATION CITY OR TOWN SlATE
<br />
<br />
<br />NAME
<br />
<br />210. METJalOf DIsPosITION 21b. DATE
<br />
<br />22.. FU
<br />
<br />.A fel.Funeral Home'
<br />22b, FUNER-'l HlJME AllOAESS ISTREET OR R.F.O. NO.. CITY OR TOWN. STATE.'ZIP!
<br />
<br />D~D~....,
<br />
<br />Lower Burrell
<br />
<br />
<br />,'," ,-.'
<br />
<br />Wood River .Nebr ska
<br />23' --.... _OlJIIlE CAUSE
<br />- PART
<br />L ""01 Brai\l- Tum?r -unknpwn
<br />~ ' '.DUE TO. OR AS A CONSEOUENCE Ol'o.
<br />
<br />;;; fI>I
<br />'O\.if'T6:0Fi' AS A CONSEQUENCE OF
<br />
<br />
<br />68883-126
<br />IENTER ONLY ONE CAUSE PER LINE FOR 1.llb'. AND (ell
<br />
<br />, .
<br />l~erwBI ~ onset aoqjseatl'l
<br />
<br />10:1'1 n s
<br />.. __0 th
<br />
<br />t:YP~
<br />
<br />Intetval ~ onset and deatn
<br />
<br />lmerval ~ ooset ancl ~ath
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<br />J
<br />
<br />Ie o'
<br />PARl"OTH€R ~NlFiCANT~S _~~?"",.~thbiA"'_
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<br />
<br />260: . , 261>.. DATE OF INUURY. (Mo.: Da,. Y'.I
<br />J.. , ' , ,
<br />o ACCldonl 0 U_
<br />tJ si;.;~;:,tr'~.
<br />0- ~
<br />
<br />"":I: LOCATION
<br />
<br />STREET OR RF.D. NO .
<br />
<br />Cn-y OR TOWN
<br />
<br />STATE
<br />
<br />',""11
<br />
<br />, ~.?".: 2:,
<br />
<br />. .28a ,OATE SIGNED ,11dr.>. (Jay. y, I
<br />
<br />
<br />4:20. p M
<br />
<br />'~~lC[0
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<br />1"'0
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<br />u~i:=:~
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<br />80
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<br />goo
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<br />;>8c PRONOUNCED OlOAD 11dr.>.. /lay. Y'.'
<br />
<br />28d. PRONOuNCED DEAD I'*"'"
<br />
<br />.M
<br />
<br />2&. On itle basiS Of eJ:.lJfl1lnaooo aMIOf' ~tJ(M"I, In my opinIOn deat... occ:urted at
<br />the """'. _ _ placo ."" due 10 hi cau..h'_.
<br />
<br />. '.....1'
<br />
<br />3O.b WAS CONSENT GRANTED?
<br />
<br />DYES fXJ NO
<br />
<br />31
<br />1 Charles N.
<br />
<br />'" "" """ " .-
<br />
<br />-l' 32.' ~G~TAAR
<br />/
<br />/
<br />
<br />IType.. _,
<br />Lye, M.D.. VA Medical Center. 2201 N.
<br />
<br />.........~ A~____."_." ____......._.__.___
<br />
<br />Broadwell. Grand. Island, NE.Ei8803
<br />
<br />'132b' DATEFliD~NOVRAR 61~ti5, ..
<br />
<br />c.; ~;
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