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<br /> ~'b 1'0 <br /> ~ ,~ n~ <br /> ...........c::., m <br /> ~~ ~ ?icn m <br /> z <br /> ~~~ ("') z ~x f.........." rri <br /> C...;;;:) <br /> i~ 0 ~~ (") (n <br /> 0 ~\ co <:> -j 0 :0 <br /> ~~ c= :t>- m <br />I\.) n~ ::n N 0 <br />IS ~~ ~ ~x ~ ~" z -j <br /> c- -I fTl ;x:.. <br />s. tTI ' C') 0 <br />(X) ~ (,-) ~ ~ "",,!:: -<0 en <br />IS ~ ~ ~ N o .,., 0 Z <br />-...J <.::) ."'rJ .........J ,., Z CfJ <br />.j:::.. t' co -I <br />W D- o :r: r'l :u <br />s tTI -0 l>- eD Cl <br /> ~ r~l ::3 ,- :;;;0 c: <br /> CJ r J:>. --.J s: <br /> c.n U) m <br /> W A ....c ~ <br /> ~ J:>. <br /> :1 t-> -........ W Z <br /> ~~ t-4 (rl 0 0 <br /> .......~ en <br /> ~I <br /> <br /> <br />l:Ili"Iji"Ij:r.>' <br />s:lJ ......(1) I-' <br />1-'1-1) (I) I-' <br />f-'rtrt <br />::r 0 <br />() -Hl <br />OCflCO <br /> <br />g5--:S <br />rtp.. rt <br />~ ......0 <br /><: I-ilI"-3 <br />...... ::r <br />ZtIlt"'lti <br />(I) 1-'-0 (I) <br />t)Ort(l) <br />11 ::J <br />s:lJ.. i"Ij....... <br />tIl Ow <br />;:.;'()~- <br />s:lJ ......ti <br />rt p; <br />~-::; <br />H::>.p.. <br />0- <br />t-h.. rt <br />::r <br />(j) 1-'.(1) <br />ti ::J <br />s:lJ Z <br />::J ;El 0 <br />p..CDI1 <br />en rt <br />Hrt::r <br />tIl ro <br />f-'l:.t:1ti <br />s:lJrof-' <br />::; f-' '< <br />p..s:lJ <br />.. ...... tl-j <br />ti 1-'- <br /><.Q <br />::r <br />rt <br /> <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STA TE DEPART1,4ENT OF HEAL TH, <br />rr CERTIFIES THE BELOW TO BE A TRUE COPY OF AN ORIGINAL RECORD O~f{I.EWrrH THE STA TE <br />DEPARTMENT OF HEAL TH, BUREAU OF VrrAL STA TISTICS, WHICH IS T!!!i~;g !!f!~J!ORY FOR <br /> <br /> <br />:::=~ 200807430 l~io~ <br />:~~~ {~~~~Tt~ <br /> <br />, STATE OF NEBRASKA - DEPARTM6JjT~F liBIJH.-=''''~,...'=O;'~::O <br />BUREAU OF VITAL ST A T1Sf.IP.$-- :~.;: "-.~';; #"'-'~'~,;- <br />CERTIFICATE OF DEAf~jF=~o _~f~=,,":-:'" <br />- .__.,~"" '.~::'- <br />1. DECEDENT - NAt,1E FIRST MIDDLE lAS' 2. SEX J. DATE OF DEATH 'Menth Doy. Y/NIrI <br /> <br />John <br /> <br />Adrian <br /> <br />Boren <br /> <br />Male <br /> <br /> <br />4. CITY AND STATE OF BIRTH idfI(J/IIl V.SA n''''''~1 <br /> <br />5. AGE. lO$l Binhdav <br />IY'S.' 69 <br /> <br />UNDER 1 YEAR <br />5" MOS I DAYS <br />I <br /> <br />UNDER 1 DAY <br />5<. HOURS MINS <br /> <br />6. DATE OF BIRTH IMonIl>. Day YoM <br /> <br />Fairmont, Nebraska <br />7. SOCIAL SECURTIY NUMBER <br />SOs.n.6016 <br /> <br />May 19, 1925 <br /> <br />Sa. PlACE Of DEATH <br />~"'T~~ 0 <br /> <br />D <br />o <br /> <br />Inpatient OTHER ~ t4lJf51ng Home <br />ER~ 0 _. <br />OOA D oone, (Sp8cdy' <br />.. <br /> <br />lib. FACIliTY. Name <br /> <br />(IIno1_IIiwSl1H/.M_1 <br /> <br />St. Francis Memorial Health Center <br />lOCATlOIl OF <br /> <br /> <br />lid. INSIOE CITY UMITS <br /> <br />Grand Island <br /> <br />1M. RESIDENCE. STATE <br /> <br /> <br />Donna Schlund <br />15 EDUCATION ISQoc,1y only h~ grade comploledl <br />E12"'Y"-'Y 10.121 CoI'l" 11-<0';" <br /> <br />MIDDLE MAIDEN SURNAME <br /> <br />1lO. STREET AND NUMBER (lncluttng Z", C_, <br /> <br />90 INSIDE CITY LIMITS <br /> <br />Nebraska <br />10. RACE - I'.g.. _. Bloc~. A_It'" n;ll.n. <br />....Il$podyl <br /> <br />Grand Island <br />11. ANCESTRY I..g.. _. lAo.It"'. GtmItn. tIC, <br />(SQoc,lyl <br /> <br />Vts IX] No D <br /> <br />13 NAME Of SPOUSE (II..... gI" _ """"'I <br /> <br /> <br />1400 USUALOCCUPATIQN {G...kirdol""""....'IH1uringmoot <br />"'_"'91i1t.-.6_1 <br />President/Owner <br />I.. FATHER - NAME FIRST MIDDLE <br /> <br />John W. <br />11. WAS OliCEASED EVER IN U.S. AAMED FOFlCES' <br />(Y...no."""".1 11",9""""""'-"'_109/18/1943- <br /> <br />Neyta <br /> <br />Faye <br /> <br />Riggle <br /> <br /> <br />21c CEMETERY OR CREMATORY NAME <br /> <br />ublic Cemete <br />CITY OR TOWN STATE <br /> <br />Fairmont Nebraska <br /> <br />4 <br /> <br />I I~al betW88n 0Il5e1 ana deafh <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I IntervallletWeen onset ana cteath <br />I <br />I <br />1 <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER' <br />Yes <br /> <br />7" <br /> <br /> <br />.~,.o:-,...,,-,. ..-. ,;;:.~__- <br />DUE TO. 00 AS A CONSEOUENCE Of. <br /> <br />lcl <br />PMT OTHER SIGNIFICANT CONDITIONS. C<w>d;Iion5 ~Ibuting .."'" _ ... nol_ <br /> <br />I <br /> <br />:/to <br />o Accidon 0 U-...nod <br />o Suocido 0 -"'9 <br />o _u. '.--""" <br /> <br /> <br />26b. DATE OF INUURY (Mo.. Day. YI.I 26c. HOUR OF lNUURY <br /> <br />26e. INJURYATWOIlK <br />y..D NoD <br /> <br />26<). LOCATION <br /> <br />STREET OR R.F.D NO. <br /> <br />CITY OR TOWN <br /> <br />STATE <br /> <br />j\"j <br /> <br />I~i <br />~f <br /> <br />270- DATE Of DEATH (Me. DIy. YI.I <br />3-22-95 <br /> <br />j\"~i <br />lis>- <br />!..~g <br />~I~ <br /> <br />M <br /> <br />280. DATE SIGNED (Me.. /Joy. YO <br /> <br />28b TIME OF DEATH <br /> <br /> <br />M <br /> <br />27b. DATE SiGNED IMo.. Day. YO <br /> <br />280. PRONOUNCED DEAD (Me. Day. YO <br /> <br />2lJd. PRONOUNCED DEAD ('*"'rI <br /> <br />P'M <br /> <br />due 10 the <br /> <br />3O.b WAS CONSEIfT GRANTED' <br />DYES <br /> <br />~NO <br /> <br />31. NAME AND AOOIlESS Of CERTIFIER (PHYSICIAN. COIIOIlER.S PHYSICIAN OR COUNTY A nORNEYI ITY<"''' Printl <br />Dr. David R. Colan, 729 N Custer, Grand Island, Nebraska 68803 <br /> <br />32. REGISTRAR <br /> <br /> <br />32t;I DATE FIlEO!3'r RE.GISTRAR (Mo., Day. Yr) <br /> <br />MAR 3 0 1995 <br />