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WHEN TH/S COPY CARR/ES THE RA/S~D SE/IL OF rHE NEBRASKA STATE DEPARTMENT OF HEALTH, !T CERT/F/ES THE BELOW TO 6E A TRUE COPY OF AN OR/Q/NAL RECORD ON F/LE W/TN.THE STATE _. ,. DEPARTMENT OF HEALTH, BUREAU DF V?AL STAT/sT/CS, WH/CH /S THE LE4i~_ _ DEPQ_S~QR_~' fOR ' V?AL RECORDS. _- - - - - - _ -- - _ ~-- ~. ._ DATE OF /SSUANCE , - ~-=- FEB 2 71995 2 0 0 9 0 6 9 9 ~, srA~v s, CpOPE~#, D/BECTCiT L/NCOLN, NEBRASKA BUI~EiQtf. ~ V/TA,L' ~Ti~TLL~T[CS` STATE OF NEBRASKA ~- DEPARTMENT OF ii@ALTJt_ - ~ - - _- _-. BUREAU OF VITAL STATISTICS _ - - - - :.. - _: CERTIFICATE OF DEATM ~' =- =-~ v 1. DECEDENT -NAME FIR57 MIDDLE LAST 2 SEX 3 DATE OF DEATH /Monm. Day. Year/ Tommy Barron Kosher Male Februa 16, 1995 4. CITY AND STATE OF BIRTH ie nd n USA.. name ddunhyl 5a AGE • Last Birthday UNDER 1 YEAR UNpER 1 DAY 6 DATE OF BIRTH /Morr9r. Dav Yearl Omaha, Nebraska IYrs~ 64 Sb Mqs I pAYS x HODRS MINS October 7, 1930 7 SOCIAL $ECURTIY NUMBER Ba PLACE OF DEATH 506-36-1218 Hos?rr~L ® Inaatwrs OTHER ^ Nurslrq H°me T ^ Resloence Bb FACILITY • Name /X revr rnsryrylpn, grve sheer arrtl numeerJ ^ ER Qu~a118n1 ~ ~[] Don ..^ Dn,~r;gnel,ry,-. _..r_--_-.-- St. Francis Medical Center . BC CITY TOWN OR LOCATION OF DEATH Btl WSIDE GITY LIMITS ae COUNTY qF pEATH Grand Island Yes ®~ ^ Hall Count 9a RESIDENCE • STATE 90 COUNTY 9c. CITV. TOWN OR LOCATION 80 STREET qNp NUMBER nncrudrg Zrp Ccwer x WSIDE CITY LIMrtS Nebraska Hall Grand Tsland 4060 Stauss Rd. 68803 ~ Yes[ "° 10 RACE - le.g~, WIMe &acz Amerlgn vglan 11. ANCESTRY le.g. !alien. Mezlcan. Garman. etc! 12 ®MARRIED ^ WIDOWED 13 NAME OF SPquSE ll/ wrM. give maroen name! g1t.l ISOeCAyI ~~yl,, YYi llte (Spxlfyl American O~ NEVER DIVORCED MA Donna Erdelt C. 1<a USUAL OCCUPATION /Grvp kuldd wqN ddne dunng mpsr 146 KIND OF BUSINESS INDUSTRY 15 EDUCATIDN (SpecM omy ngtleal grade cwnpeladl d WOrkMg MN swrr n reared! - Service Manager Truck T~easin Elemerna a 5ecarlaa 10121 Cdlege n.a nr s-i 8t~i Grade ~ 16 FATHER -NAME FIRST MIDDLE LAST M;ITHER FIR51 MIDD: ~ _M MAIDEN SURNAME ~- Herman NMI Kosher (Dec.) Effie NMI tTR1K Dec. 18. WAS DECEASED EVER IN LLS. ARMED FORCES? 1 ga INFORMANT -NAME Ives. n°..or unk.l In yes give war antl tlales d servwesl Yes Peace Time 1947--194$ Donna Raeber 19b. INFORMANT MAILNM ADDRE55 (STREET OR R.F.D Np.. CRY OR TOWN. STATE. ZIP( 4060 Stauss Rd., Grand Island, Nebraska 68803 2D. R-SKiNATVREd LICENSE NO 21 a. MEfHpp OF DISPOSITION 216. DATE 21c CEMETERY pq CREMATOHYNAME ~' ~//~S X^ Buriel ^ Removal Feb. 18 1995 West Lawn Mausole II2a FUNERAL HOME • NAME 21tl CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Kleine Wiest Funeral Hame ^ D'am' ^ Grand Island Ne 2'Jh a 1uKpal I•IrMAF ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN . STATE. Z1P1 3213 W. North Front St., Grand Tsland, Nebraska 68803 I f'~. IMMEINAr~`CAUSE ~~~~ ) ~IENTER10~N-L;O~(~5` ER LINER Ial. Ibl. AND Icll i ~. IrrlervaT I batwcen onCS\et and deem PART ~ ~ ~..~`ry` ~~VU •_rl~l.~~~~1_`1- ,/\a 1 1 Idl ~ \ Dl1E TO, OR AS A CONSEQUENCE OF I Interval between ahem and tlean, __161 C~ LvcvC~ I w~~~~ DVE TO.OR AS A CONSEIXIENCE OF ~ -_ ~~ ~ ~ W it Interval between ansn and deem OTHER SIGNIFICANT CONbITK'N15 -Conditions camrfbueng to tl1e death 6u1 nol relatetl PART III IF FEMALE. WAS THERE A AUTOPSY .WAS CASE REFERRED TO MEOIGAL PART II PREGNANCY IN YHE PAST 3 MONTNS~ E%AMINER OR CORON ~ (Ages 10-bal Ye6 No Ves No Yes No 28a. 286. BATE OF INJURY /Ab. Day. Yr,J 28c. HOVR OF INJURY 28d. DESCRIBE HOW INJURY OCCURRED AccWem ~ Undelermined M Suicide ~ Pending 28e. INJURY AT WORK 28f. PLAp E61dItlIngJ~ V • At hone, !arm. sVeet lathy dMhltc •- CI(yl 26g. LOCATION STREET OR R F p NO CITV OR TOWN STATE Hpni°ide Invey7lgaaon Yee ^ ~ ^ Yr.l . DATE qF DEATN /Mo O a Y 217a DATE SIGNED /M1M.. OBY Yr l 296 TIME OP l7E.ATH ^ ~' ~) ^ 1 ~ (~; \ am' E~ C.i' ] l J s a i M `~'s pATE SIGNED /Ab Day. Yrl d. TIME OF DEATH i k r 28c PRONOUNCED DEAD lMn. Day. YrJ 28d. PRONgUNCED DEAD /Mprlrl S ~~ ~ ~~ J tiJ .] M ~ a ~ ~ .,_.... M ° ~ d To the best d my ledge. dea tarred at me b , date antl lace a duuu~~~to me ° ~ ° 28e On the basis of ezammauen and ar mvesganon, m my ppmon Deem dc:curretl a1 teasels! steed. ` \ ` ~~ _ me mm~, data antl place ono due t° the teasels! stated. I5 nacre and Title - V ~ 1~(1 `L IS nears and tme~..p - DID TOBACCO USE C T E TO HE DEATH? a HAS ORGAN OP TISSUE DONATION BEEN CONSIDERED WAS CONSENT GRANTF.p~ YES NO ~ UNKNOWN ~ VES Np ~ YES 31. NAME AND ADDRE55 CERTIFIER (PHYSICIAN, COFtONER~S PHYSICNN OR COUNTY ATTORNEY( /Type n-Prmr/ Jahn J. Cannella MD, PO . Box 2339, Grand Island, NE 68802 32- REGISTRAR 32b pATE Fp.ED 8Y 5~'jC7~R ~~~5