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<br />WHEN THIS Copy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HV/MNSERVlCES
<br />SYS1EA( "CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RE~tf1Ja"e.W1TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAnST~~~~
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~dJ. ~:.-,~~y:ttl d~=';.j,-
<br />- .. iI~ viut~ '
<br />DATE OF ISSUANCE 200805727 ,~-~~"~.tcfo.ol~'
<br />JAN 1 7 2002 ASSIMll!trsTAfEREGlS~~
<br />LINCOLN, NEBRASKA HEALTH AND. H~N~l!r!<<tt!trE~
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALnt AND HUMAN SQYlClj$ ~4tP SutfoRT
<br />VITALSTAnsncs 'n .." ~-_O ,"' ~.~ 2 00259
<br />CERTIFICATE OF DEATH -o~~~=-~=---'-ll,
<br />1 DECEOENT.. NAME. FIRST MIOOLE LAST 2. SEX J. PATE OF DEATH (Month, Day. Year)
<br />
<br />William
<br />
<br />Baxter
<br />
<br />Jones
<br />
<br />Male >
<br />
<br />January 14, 2002
<br />6, DATE OF BIRTH iMOrtth, Day. Y.ear)
<br />
<br />4. CITY AND STATE OF BIRTH (If not in U.S.A.. f1amecO/Jntryj
<br />
<br />5a. AGE - Last Birthday
<br />(Yrs.176
<br />
<br />UNDER 1 YEAR
<br />5b MOS DAYS
<br />
<br />UNDER 1 DAY
<br />50. HOURS' MINS
<br />
<br />Julian, Nebraska
<br />7. SOCIA~ SECURTIY NuMBER
<br />
<br />April 16, 1925
<br />
<br />Sa P~ACE OF DEATH
<br />
<br />505-22-5737
<br />
<br />HOSPIT ALe
<br />
<br />o Inpalianl
<br />o ER'Outpalienl
<br />o DOA
<br />
<br />OTHEFI: 0 Nursing Home
<br />[:xJ ~esldence
<br />
<br />o Other (Sf)6C,fyl
<br />
<br />8b. FACILITY - Name (II not Instirution, give streer and nl,.Jmt;1er)
<br />
<br />1612 N. Illinois
<br />
<br />
<br />8e. CITy. TOWN OR lOCATION or DEATH
<br />
<br />INSIDE CITY ~IMITS
<br />
<br />COUNTY OF DEATH
<br />
<br />Grand Island
<br />9a. RESIDENCE - STATE
<br />
<br />Hall
<br />
<br />
<br />9d, STREET AND NUMBER /lnC1ua;ng ZIp C()d~J
<br />
<br />ge, INSIDE City liMITS
<br />
<br />Nebraska
<br />
<br />68801 Ye, [] No 0
<br />
<br />13 NAME OF SPOUSF. (II Wife. give ma/t1srJ (lame!
<br />
<br />eto.IISpee,fyl Wh i t e
<br />
<br />11. ANCE.ST~y ji;!.g Italian. Mell"lCan, Getman. elcl
<br />(SpeCify) American
<br />
<br />Leonora Hrub
<br />, 5, EDUCATION (Spep'Y only hlgMst grada compleledl
<br />!::lemenlafY or SaCOf\dary (0.121 COllege fl-4 Of S+I
<br />12th Grade
<br />MIDDu:. ~ MAIDEN SURNAME
<br />
<br />148. USUAL OCCUPATION (Give kifld of work done during most
<br />of wor~mg life. evon If rff!firf!d!
<br />Truck Driver
<br />16. FATHER :-NAME FIRST-.
<br />
<br />Gasoline
<br />LAST
<br />
<br />MIDDLE
<br />
<br />De:),phia
<br />-NAME
<br />
<br />Coulter
<br />
<br />Yes
<br />Hlb. INFORMANT
<br />
<br />Jones
<br />
<br />1612 N, Illinois
<br />MBALMER - SIGNA TURE & LICENSE NO
<br />V(.~1t:111-3
<br />
<br />
<br />Grand Island Nebraska 68801
<br />2'.. METHODOFDISPOStTION 21b. DATE
<br />
<br />21C, CEMETERy OR CREMATORy NAME
<br />
<br />~8uriat
<br />
<br />o Removal
<br />
<br />Jan. 17, 2002 Grand Island City Cemetery
<br />21'. CEMETERY OR CREMATORY LOCATION .., CITY OR TOWN STATf
<br />
<br />NAME
<br />
<br />Li vings ton-Sondermann F, H, 0 C,e"'a"on 0 Dooahoo
<br />22b. FUNERAL"HOME ADDRESS ISTREE T OR R.F 0 NO.. CITy OR TOWN. si"A'i'.E.-ZiPj
<br />
<br />Grand Island, Nebraska
<br />
<br />601 N, Webb Road,
<br />23. IMMEDIATE CAuSe
<br />~~RT c.(\N L6 ~
<br />'" lar
<br />DUE TO, OR AS A CONSEOUENCE OF.
<br />
<br />Grand Island, Nebraska 68803-4050
<br />-. IENTER ONLY ONE CAuSE PER ~INE FOR lal.lb), AND lell
<br />a~ -Z \.,~ L--WN
<br />
<br />c,.
<br />
<br />Interval between Onset ano clealh
<br />
<br />: -r ;} '-\.. ~ J\ ll-..t"~
<br />
<br />Interval between onset and death
<br />
<br />."-~"..--.._".'.'
<br />'-O'U['i'O-:'OR AS A CONSEQUENCE OF
<br />
<br />I
<br />~' ,~-:::,~-~.~ I
<br />I Inter\lal ootween onsel and oe(llh
<br />I
<br />I
<br />I
<br />25 WAS CASE REFERReD TO MEDICAL
<br />~XAMINER OR CORONER'
<br />
<br />,..-::,"~-
<br />
<br />~
<br />
<br />Ie)
<br />PART OTHEA SIGNIFICANT CONDitiONS. Conditions contributing 101M death bvI not related
<br />
<br />II
<br />
<br /> 260
<br /> 0 Accident 0 Unclelermine(j
<br />I 0 Suicide 0 Pencllng
<br /> 0 Homicide Invesligalton
<br />
<br />
<br />2Gb. DATE OF INJURY (Mo.. O.y. Y<./ 2&. HOUR OF INJURY
<br />
<br />260. INJURY AT WORK
<br />Yes 0 NO 0
<br />
<br />26g. LOCATION
<br />
<br />STREET OR RF.D. NO.
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />27a. DATE OF DEATH (Mo Day Yf)
<br />\ \.\
<br />
<br />2Sa. DATE SIGNED IMo. Oay y,)
<br />
<br />28b TIME OF DE;ATH
<br />
<br />k'"
<br />
<br />0\
<br />
<br />L-O\"J L--
<br />
<br />
<br />S:1
<br />~ .27b DATE SIGNEO (MD. Day Yr,j
<br />p
<br />:?~)-- 0 \.- \.. '----t..... .~. '1..<-=,,::;L
<br />o~
<br />~<<
<br />
<br />M
<br />
<br />27c, TIME OF DEATH
<br />
<br />28c. PRONOUNCED DEAD IMo.. Day, Yt)
<br />
<br />28d. PRONOUNCED DEAD lHo'N
<br />
<br />y
<br />
<br />o C\.... "L~A l\:--~
<br />
<br />M
<br />
<br />On 1M basis 01 ex~mination aMIOf inve$bgalion. in my opinIon aealh occurred at
<br />the time. date and place arid due 10 the causelS] S1aled,
<br />
<br />EY I (T YfJ8 01 P,inlJ _
<br />;).~ l N
<br />
<br />JO.b WAS CONSENT GRANTED'
<br />r 0 YES ffi-,-.
<br />
<br />f\,,(U.J ""n LA1 ~ f\-v ~-''-i ....)\'::- )
<br />.e. 1'-~1'o,J C') 1..QU'H',j 0 f'J...:- 6MQ ':", ,
<br />32b. OA TE FILED BY REGISTRAR (Mo.. Day. Yt.)
<br />
<br />JAN
<br />
<br />
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