|
<br />i
<br />G7~ ~~~} ~ ~ ~ I i.i OMANA•DOUGUS COUNTY HEALTH DEPARTMENT ~
<br />Vitel Statizties Section ti~E~.d~ 3 I
<br />CERTIflCATE OF DEATH
<br />
<br />-~~ DECfefHi-NAME i14ST MIDN.` UST 5Fi - 'DAfE Oi DFA1N (Mb, OoY. Yr.)
<br />Elizabeth C. 1
<br />_Kob! tz =Female , h~~ i?~, )9s2
<br />... FACE-(•.q.whn.,lle.Y,Am«iibn ORIGIN/DESCENi1•g.Irelivv,M~.icv AGE-WV R~nwer ~UNOFR I.YEAA- UNOE47 AY DAT OF SIRfH (Mb.. pay, Tr)
<br />~
<br />Ind%en, •N.) f5ptury) GRrmvn. erc.) (Sp«ifY)
<br />I lYr.) I MOS DAYS ; NOU[5 • HMS,
<br />• ll'Q__ 5. rlih !fe 7~ i~b _-::_-_Id._ _~ 7 pecetrlber 6 1906-
<br />CITT AND STATE Of [IRTN ft/wer .n U.S-A., iCIUZEN OF WHAT COUNiRYMARRIED, NEVER MARRIED. NAME Of SPOUSE (Iirile, qiw me•den~em•)
<br />_ I iwIDOWED DIVORCED (SpwcrFT1
<br />. ~
<br />9ro~cen t3aw Nebroslca L R. U. S. A. Ilo VYldowed i
<br />_ ~
<br />-~__ f l
<br />SOCIA: SECURITY NUMSfR" USUAL OCCUPA110N(G%•: find of .er5 den. dVrrng mbd RIND Oi eU51NE530RINDUSiRY
<br />~ COUNTY Oi DEATN
<br />~~/~ +3~~ vF.drkinq l.fr" n;F nF:r.dl_L__
<br />I2. 505-01-1335 .Ilv. ~enOrirapher 1136: SI (a e~
<br />~ i)~ -
<br />i.a.
<br />- CITY, TOWN OR LOCATION OF PERTH
<br />IINSIDE CItt LIMITS HOSPITAL OR OTHER INSTITUTION-Nanw (I/ner:n •dher, IF NOSr OE rN51. Indimr•DOA,
<br />.. ,(Spee'Fr T•r vNe) O.eperr•nr/fwhr. Rw., .nr(SP«dYl
<br />q:r
<br />n
<br />,rnb.
<br />r)
<br />d
<br />1.6. 114. Y (
<br />T
<br />~
<br />/
<br />` ['
<br />IAd-~~~87 1a_~7 ).
<br />[ESIDfNCF-STATE GOUNtt - CItt, TOWN OE LOCATION STREET AND NUMAER INSIDE CItttU.UTS '~
<br />i3e.
<br />Nebraska ISb. D las ik.
<br />I Omaha O'7/1L S~
<br />Isd. O/l/V n " (SP~i 1n ar Ne/
<br />Ls..
<br />_
<br />AlH -NAME FIRS MIpOtE- LAST jMOTHER-MAIDEN NAME FIRST- MtODLE - LA3T
<br />,D. John Sweeney ~„ Nellie McCiowali:.
<br />i
<br />_ WAS DECEASED EVER IN U.S. ARMED FORCES? INFORMANT- E ~- Ac'_A:10NSHIP-MI11tING ADDRESS - ISitfEi O• R r,e HD., d^ Ot fOw S Elrl
<br />Ou n'o. •nlfi 111 nv R'+.e• one derv •I .,m.r•, i
<br />I[. Fvo , I9. Raui Sweene~Brother 1311 W. let Grand island !`ii~a- i
<br />BUFUI. C.vmetien, RnmmvIIDATE CEMETERY OR CREMATp RY-NAME LOCATION- - CFTY OR TOWN STATE r
<br />mP. Buricl I2D6 16 1982 =fk O'Cc3uLO_rSl~u[rh 4en 2Dd.
<br />~;
<br />EMR E -SIGN.LIURE d LICENSE NO. FUNERAL HQME -NAMf AND ADDRESS LST9 [T De R i.D. NO., CUy Da iOwN, Siw C ZipF _~~p;n
<br />W
<br />/6
<br />_, :~25 i22 T. J. Firm & Sons 103 Soe Galw Greeley. Nebra~c
<br />a'
<br /> O TE OF DEATH ( .. er• Yr.l I DATE SIGNED (Me. DaY, Yr.)
<br />HOUR Of DEATN _
<br />-
<br />9.2
<br />_ I
<br />i
<br />(iC
<br />ne. August 12 , 1982 1;„0 ~ 2+c. , 2+6. M
<br />
<br />~;! ~
<br />DAYf-SIGNED (Me., Dvr, Yr.) iHOUR OF DEATN
<br />I{
<br />ROND ,NY E
<br />D DEAD P0.0NOVNCED DEAD (Heurj
<br />'d.
<br />°~ I
<br />)
<br />~•
<br />!
<br />8-16-82
<br />2:00 P
<br />M
<br />i
<br />e'
<br />~
<br /> .
<br />r~2
<br />=,,.
<br />. M !
<br />nb.
<br />xl~.
<br />xAd
<br />:
<br /> b« ^P L^e.l•dR•. dwrh eeu..M ee rb, nm., der. o p e.• one d., ro H., 1
<br />O
<br />au
<br />endie n
<br />H
<br />O m
<br />anew :. .en d,e.b «w.r.d et
<br />e«,L•I sroHd
<br />n I
<br />•
<br />e
<br />na
<br />M
<br />ep
<br />• M
<br />,
<br />.
<br />I
<br />da n
<br />N a
<br />d v «. o
<br />dd •a M•
<br />..WJ.rer
<br />.
<br />/~
<br />-
<br />~~~
<br />,
<br /> x3d.!9enem.. end^p:: ~SZ v.E. Baca, M.D.
<br />j
<br />2...rs~e,e..»e«F
<br />r.a.,!
<br />NAME AND ADDRESS OF CERtIf TEA (EMYSLCtAN, CORONER'S PHTSLCfwN OR COUNtt AYfORNEYJ (Type ar P.;nrJ
<br />u D.E. Berea, M.D•, 2580 So. 90th Stn, OLnaha, ME 68124
<br />[FGI$lRAA ( ~[ n ~,) )/r ~~• ;GATE 0.ECEIVE
<br />D E
<br />Y
<br />RE
<br />G
<br />I
<br />S
<br />TRAR (MV.. DPF, Yr.)-
<br />-
<br />V~
<br />.n'
<br />,-F•'fi-l
<br />L
<br />• •
<br />~
<br />O
<br />t
<br />-
<br />~
<br />(
<br />3
<br />/
<br />~L
<br />(
<br />~
<br />p
<br />26v.I3:yneru.•)g
<br />/
<br />~IAb ~ 1 J 7Jt7~
<br />27. IMMEDIATE UUSE (FNtFA ONLT ONF A E PfA LINE fOF {b), (b). AND Tc)J L h•Iw•n •erf and AaM
<br />I
<br />PART ~
<br />- _
<br />i•1 Inanition, Ca Bronchus-Collapse of Right Lunq Weeks ~
<br />DUF TO. OR AS A CONSEQUENCE OF: ~Mr•mel b.•w.a an.er b:d d•aM
<br />,,, Collapse of Lung Due to Br. Obstruction Days.
<br />' DUE TO. OR AS A CONSEQUENCE OF- Nrv.l berw•n e,.« and deM
<br />(cl
<br />IA[T iMfR SIGnIfKw,ri COHD1110H5-Ce.d:r~en. Cw•,.brr ~ A.e•4 E.'.-a-a: ..I.eN ~ a' t r -' E ww5 THERE A w :OPSi wAS GSf RFFERIIfO TO MEDICAL
<br />II .iFGNAHCYIn HF PwSi 1 MONTHS? (Sp•aH •x e• Nd FIfAMINFR CH LOIONlR
<br />~
<br />r3P«,r,t..«N.,
<br />Cardiac Decompensation ! Y•,c Nbe
<br />i xa NO i=s.
<br />_
<br />AC<IDENI, SUICIDE. HOMFCIDE. UNDEt ,' DAff Of INIURT (Mn, Der, Tr.) HOUR 0/ INFURi DESCMRE HOW FNIUft OGCUERFD -
<br />OR rENgNO INVESIIGAigN. (Sp«:F,l -.'-- - - ,
<br />~
<br />~
<br />30e. xDbb~
<br />3fk.
<br />30d. '
<br />IW URY Ai WOR[
<br />l MACE yNNE-A1nnm•. A.rg.±h«r, loc+ery, IOCA:IOH - STREET OR Rf D. Ne. CISYWtOWN STATE
<br />>
<br />(Sp«i
<br />r 1« w N•1 ..
<br />>u~'dMy.,TM-fta•.%Z>I '
<br />~
<br />]G. _ _
<br />-_ ~30R.
<br />
<br />/+CL /1~ 8W'O t,2~~,L./_-~~.OL{~L C~Y~R lI~ D ~/}
<br />- ~ C.Q+w 1"..te~2.. l•~ac~F.w.G~ ~ tr'ij cj ~/.
<br />RECORDERS MEMO: - __~s L.;. !~~ ' ~Y~ x'r
<br />~ g. of Dee
<br />t-
<br />This certifies this docermexgt to be a true cony of an original record on file
<br />with the Omaha-Douala§ County Health Department, vital Statistics Sec~~}}t6ilon,
<br />AU61 9.1982 ~~~~'"t'+ ~'t",~'
<br />Date Issued ~
<br />Registrar
<br />L~
<br />
<br />
<br />~._
<br />
|