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<br />200806279
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<br />WHEN THIS COPYCARRJES THE RAISED SEAL OF THE NEBRASKA HEAL'ltl.ifNV~N SERVICES
<br />SYS7E'M, "CERTIFIES THE BELOW TO BE A TRUE COPY OF THE OR~" ~/LE WITH
<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VlTALmliii~:~/jf{F~iCH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. =-,;~~~, -;:,~~-~'o;~::-',~, OO,:r-:/,,~W,'~ :"'€,~"o,'
<br />
<br />DA TE OF ISSUANCE ~~ :_...:: "-_,, . fl. ,~,e......
<br />OCT 7 1999 ~~ ::::. i ' 0-.:....00 = &f1f1OPER
<br />Ii. ~/STANT STA ft! itiiGJjTRAR
<br />LINCOLN, NEBRASKA HEALTI/N#.riHJJMA.tL~-'~STEM
<br />STATE OF NEBRASKA- DEPARThffiNT OF HEALlH AND ~ siR~ANCE~ SUPPORT
<br />VITALSTA11S11CS -'-cc:,.:=:;c:: ,",0" - ".~~'=""
<br />CERTIFICATE OF DBA ~- ~:...~ ~=--
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<br />4. CITY AND STATE OF 61RTH IHnot'" USA. na"", countryl
<br />
<br />
<br />UNOER 1 YEAR
<br />Sb, MOS, OA YS
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<br />" DECEDENT - NAME
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<br />FIRST
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<br />MIDD~E
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<br />LAST
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<br />2, SEX
<br />
<br />{Month. DP'y. Yeaf'
<br />
<br />Russell
<br />
<br />Lowell
<br />
<br />Goins
<br />
<br />White
<br />
<br />11. ANCESTRY le.g.. Italian. PM.ican. German. &tel
<br />{Specdy, .
<br />Amerlcan
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<br />ler
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<br />~Fairfaxf Missouri
<br />c"... 7. SOCIA~ SECURTIY NUMBER
<br />UI
<br />:o!I487-14-4463
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<br />..1 00. FACILITY. Namo
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<br />"1St F . d'
<br />~ . ranC1S Me lcal Center
<br />.... 8c, CITY, TOWN OR LOCATlo.foF DEATH
<br />
<br />{N not m$_ gi.. srrHlaM_I
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<br />~~PI~l IX] Inpatient Q!~,~ [j Nursing Home
<br /> 0 ER OoIpatiOnl 0 Re.5idence
<br /> D DOA 0 Other (Sveclfyl
<br />
<br />MIDD~E
<br />
<br />
<br />s,..., iNSIDE ~i"Y LIMnS
<br />
<br />Grand Island
<br />90, RESIDENCE - STATE
<br />
<br />10. RACE -(e.g" WMe. Black, American fndian.
<br />elc.lfSpec,tvI
<br />
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<br />Yos [Xl No D
<br />
<br />Nebraska
<br />
<br />14', USUA~ OCCUPATION IGive bMofworl< donedlJlingmosl
<br />1',] of worAiflg lifB. 8VMJ if rMired}
<br />~ Owner/Operator
<br />~ 18, FATHER - NAME FIRST
<br />''-041
<br />3 Leslie
<br />.::I 18. WAS DECEASED EVER IN U,S, ARMED FORCES?
<br />lYe!;:. no. Of vnk.) I fit yeS. gIVE!' Wiilf ~r'(I diilfe!;. 01 services)
<br />!NO
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<br />Restaurant
<br />LAST
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<br />191), INFORMANT
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<br />MAI~ING ADDRESS
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<br />Granc Island Nebraska
<br />#/Z/Z- 218, METHOD OF DISPOSITION 21b DA-'E
<br />
<br />68 01
<br />
<br />~CEMETERY OR CREMATORy NAME
<br />
<br />~BUnal
<br />
<br />o Removal
<br />
<br />28 ~ Mffirrial'Park Q.::netp ]
<br />21d EMETERY OR CREMATORY ~OCATION CITY OR TOWN STATE ry U
<br />III
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<br />Grtmd 1...1 nnd, Nehra...k<'l.
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<br />el-B.Jtler-G:rl:.'?es F\n:!r:al fbre In::. D '~'Om'liOn D Oonaloon
<br />2:>b FUNERA~ HOME ADuRESS (STREET OR R.F.O. NO. CITY OR TOWN. STATE, ZIP)
<br />
<br />IE TER ONLY ONE CAUSE PER LINE FOR lal, {bl. AND fell
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<br />Interval berwe
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<br />(b)
<br />OUE TO. OR AS A CONSec.<JENCE OF;
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<br />25, WAS CASE REFERRED TO MEDICA~
<br />EXAMI~ER OR CORONER'
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<br />death
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<br />IntefViill between onse1 and death
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<br />PART OTHER SIGNIFICANT CONDITIONS . CoM~ions con.ributlng 10 tho doa,n bu. Ml rotated
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<br />'-041 E~
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<br />260,
<br />
<br />26(>, DATE OF INJURY {Me.. Day: Y'.J 2Sc, HOUR OF INJURY
<br />
<br />o Accideo' 0 Undetermined
<br />o SuiCH:le 0 Pending 268. INJuRY AT WORK
<br />o Homic:iQe Investlgabon
<br />
<br />26g. ~OCA TlON
<br />
<br />STREET OR RF.D, NO,
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />288. OA TE SIGNEO lMe.. D<<y: yo
<br />
<br />28b TIME OF DEATH
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<br />2Sc. PRONOUNCEO DEAD IMo.. Day. Y'.J
<br />
<br />280. PRONOUNCED DEAD lHov'1
<br />
<br />1.1
<br />
<br />1.1
<br />
<br />288. On the basiS of tlCarNnaOOn and10r investigation, in my opinion dea1h occurred at
<br />tho timo. d......., plsco ,oddue 10 tho caUS8/s)otated_
<br />
<br />DYES
<br />
<br />Jetb WAS CONSENT GRANTED'
<br />o YES ~'
<br />
<br />31, NAME AND ADORESS OF CERTIFIER fPHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY' (Typo 01 Printl
<br />
<br />rdon J. Hrnicek,
<br />320. REGISTRAR
<br />
<br />
<br />{MIl.. Day. Y'.}
<br />
<br />SEP 30 1
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