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<br />, L:\mf!~;i1r)t::~,
<br />
<br />WHEN THIS copy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANQIJ!;1MAf!-,-~.,aJ!S
<br />SYSlFM, "CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL ~~IfL~
<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA TlSTl4S1lSfn__~IqfJ~;-..
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~;;_~?J~~~~ \
<br />
<br />DATE OF ISSUANCE _"._ ~:-o == :. _--
<br />ii' RIErS:(;Hpe~. F:
<br />DEe 1 1998 200 90000 2 ASSIS7Mr &TAU" REGlJmAlf 11
<br />LINCOLN, NEBRASKA HEALTH AND HU. ~~-~ftEIt!!ff
<br />STATE OF NEBRASKA. DEPARTMENT OF HEALlH AND HUMAN SERvi~~~~~T
<br />VITAL STATISTICS ....,'" ""'._ _ ..',"',c",-'
<br />CERTIFICATE OF DEATH --,-=""-
<br />
<br />,. DECEDENT - NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />\.//
<br />Alva
<br />
<br />LAST
<br />
<br />2. SEX
<br />
<br />3. DATE OF DEATH IMoo",.o.y, y..."
<br />
<br />Grover
<br />
<br />Alexander
<br />
<br />Male
<br />
<br />October 19, 1998
<br />
<br />'. CITY AND STATE OF BIRTH IN ncI kl U.S.A.. no"," CO<J(I(ry)
<br />
<br />St. Paul, Nebraska
<br />
<br />50. AGE - Loot allII1dav
<br />IY"I 79
<br />
<br />ea. PLACE OF DU TH
<br />
<br />HOS~ITAL: D
<br />
<br />D
<br />D
<br />
<br />UNDER I YEAR
<br />~O. MOS. DAYS
<br />
<br />UNDER 1 DAY
<br />5<:. HOURS' M'NS.
<br />
<br />e. DATE OF BIRTH 1_ o.y. y""}
<br />
<br />::::I
<br />.... 7. SOCIAL SECURTIY NUMBER
<br />~ S06 18 4289
<br />n.
<br />.] 811. FACILITY. Name !Nnct,notiM/oll,g,..,/fHllfl(inUfflW}
<br />:~ VAGNHCS 2201 North Broadwell
<br />BC..CITy.'TOWN OR LOCATION OF DEATH
<br />
<br />September 12, 1919
<br />
<br />Inpallon! OTHER llil Nurlino Home
<br />ER OuIpa\ionl D Ra'.aeno.
<br />OOA D OIhar 15p<</ly1
<br />
<br />Nebraska
<br />
<br />
<br />
<br />eo coUNTY OfOEA TH
<br />
<br />.~..n ~~_ lJ_1... __1._
<br />.___~_" ,'" '."'.~r,~"":...._
<br />. ... ,_ "n "",.' ._
<br />Ila. RESIDENCE . STATE 90. COUNTY
<br />
<br />Dol. STREET AND NUMBER l'fIC1fJdIn{J Zip ea.)
<br />
<br />9&, INSIDE CITY LIMITS
<br />
<br />68801
<br />
<br />YOII!! NO D
<br />
<br />10, RACE -I..g., Whll..'8Iac.. Am.rican Indiao. II. ANCESTRY 't.g.. ntllan. Ma,iean. G"""".alCl ~ 12. I!] MARRIED 13. NAME OF SPOuSE IN_. givo""~_}
<br />
<br />.'e.IISpoc,ly) White ISpoc;fy1 Scotch NEVER Matilda E. Pauly
<br />
<br />"0. USUAL OCCUPATION IGw" kind Of worlr rJone during most 100. KIND OF BUSINESS INDUSTRY 0 U> 0 1~. EDUCA TlON ISpecily ""'V higholt llflda cDmplal<Jd)
<br />
<br />~Sh:cl,ngMe"t~Ii"Worker, Ret. Heating and Airconditioni gEleme01Oty"'mtt 10.12) College 11.00/s"
<br />
<br />~ 16. FATHER - NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />
<br />'~04{ ( )
<br />... Dee.) Alva Henry Dec. Jessie Marie Gaast
<br />'. 18. WAS DECEASED EVER IN u.S ARMED FORCES?
<br />IYy.'e' ODS' D' uo'.1 WW'll '.'1' giIVO ..olr 0'J'lsd07'4DI3"""""_' 0.\ 1 / 2 9 / 4 6
<br />I Matilda E. Alexander
<br />lilll. INFORMANT MAILING ADDRESS iSTREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />
<br />
<br />
<br />Island, Nebraska 68801
<br />210. METHOD OF OISPOSITID~ 21b. DATE
<br />
<br />21e CEMETERY OR CREMATORV NAME
<br />
<br />rn Burl.1 D Rom",o' Oct - 22, 1998
<br />
<br />West lawn Memorial Park
<br />
<br />21d CEMETERY OR CREMATORY LOCATION
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />Apfe1-Butler-Geddes
<br />
<br />D Cremation D OooallOn
<br />
<br />Grand Island, Nebraska
<br />
<br />22b. FUNERAL HOME A~DRESS
<br />
<br />ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />
<br />1123 West Second,
<br />
<br />Grand Island, NE.
<br />
<br />68801
<br />
<br />23. IMMEDIATE CAUSE
<br />PART
<br />'Ia) Right Lung Pneumonia,
<br />
<br />DUE TO. OR AS A CONSEOUENCE OF'
<br />
<br />IENTER ONLY ONE CAUSE PER LINE FOR la). 101. AND lell
<br />\'1)
<br />
<br />Inlerval between onset ancl oealtl
<br />
<br />...
<br />!,)
<br />...1
<br />
<br />~~.:":~>lW~~;U,, Cell CA
<br />_ .- QUE TO. OR..A~.A,"?~5EOil~ OF,
<br />
<br />1ntef'l,lal ~ onset and death
<br />
<br />""HI. H....t.!l of Skin of Rt. Arm with Mets
<br />
<br />1",~
<br />
<br />ilIi/o, ~,. -.
<br />
<br />~'lp~
<br />
<br />...
<br />
<br />l~hl.:ll ~ai. (;..~~ and t.~,,_ _~._
<br />
<br />260. INJURY AT WORK
<br />Yes 0 NO D
<br />
<br />
<br />I
<br />,
<br />2~. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER'
<br />
<br />Icl CO PO
<br />PART OTHER SIGNIFICANT CONDITIONS. CencllIion, contributing to Iho <loalh but 001 "".1Od
<br />
<br />II Alsheimer Disease, HTN
<br />26a 2Gb. DATE OF INJURY (Mo.. Day. Y,., 260 HOUR OF INJURY
<br />
<br />D Accident D Undetermined
<br />o Sl,Jlcide 0 P'mdtng
<br />o Hornn:ade Inve511gallQf'l
<br />
<br />260. LOCATION
<br />
<br />STREET OR RFD. NO.
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />27a. DATE OF DEATH (!lAo" Day. Vr,J
<br />
<br />28a. DATE SIGNEQ IMo... Day y,)
<br />
<br />28b. TIME OF DEATH
<br />
<br />October 19,
<br />
<br />1998
<br />
<br />~~ I" ~
<br />- ~ >-
<br />~ 109
<br />~ ~f
<br />~J """" '<I;:
<br />.]
<br />
<br />7:15
<br />
<br />PM
<br />
<br />~>-
<br />i ~ ~ >- 28c PRONOUNCED DEAD IMe OIlY. Y'I
<br />~ffi~g
<br />
<br />~ ~ u. 28e On the basis of examlna110n and/or If'lvelttganon. In my opInlOl1 death occurred a'
<br />S the tIme date and ~ce ancl clue 10 the cause(5) stated
<br />
<br />M
<br />
<br />27d. To the be:!>1 01 my knOwl4!!lOge. death occurr
<br />caUS$(s\ 5tatEtd. /1
<br />
<br />. (Slgnaiufe and 'titlel'" ( ~
<br />29 DIO TOBACCO USE-C.ONTAiBUTElD THE DEATH?
<br />
<br />DYES . 0 NO [!] UNKNOWN
<br />
<br />
<br />27e TfMEOF DEATH
<br />
<br />28<1. PRONOUNCED DEAD lH<wfi
<br />
<br />M
<br />
<br />.__._. I ISignatufe and Tittel'" .._.____.._ _..
<br />.0 AS ORGAN OR TISs0r6oNATlON BEEN CONSIDERED' 3O.b WAS CONSENT GRANTED'
<br />
<br />( D~ OO~ D~
<br />
<br />[K] NO
<br />
<br />31. NAME ANQ ADDRESS OF CERTIFIER IPHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) ITypo Of P,int)
<br />Iftekhar
<br />
<br />Grand Island, NE 68803
<br />
<br />32. REGISTRAR
<br />
<br />32b. DATE FILED BY REGISTRAR IMo... o.y. Yr.}
<br />
<br />NOV181998
<br />
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