200501896 - Laserfiche WebLink

Browse

WHEN THIS COPYCAM S THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN D ICE'S SYSTEjK R CERTF ES THE BELOW TO SEA TRUE COPY OF THE ORIGINAL. RECORD E ITH J THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS' THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE _ JAN 2 5 2005 200501896 ASSISTA� ' � "°- LINCOLN, NEBRASKA HEALTH AND HIJINJN >w � STAl MCFIURAW. A- DQARIMMOFENALINAADiRAI /AIIISBRVIMFDWCBAID _ VITAL STATSM CERTTFICAT'E OF DEATH ;. 1 DECEDENT • NAVE FIRST MDOL LAST 2 SEx 3 DATE OF .. IV%I T SOCIAL SECURITY NUMBED . !�S'TAL WIMM' OTHER ❑ N 01e uwv." 508 -28 -8991 FA O m FAQUTY • NrM pFnor.NrlwL. p rAl.Ir.angM+nerl ❑ IIot/nr ❑ RAKE St. Francis Medical Center n D0A ❑ ~f - -- ac QTY TOWN OR LOCATION OF DEATH !e INSIDE CITY LAMS M COUNTY OF DEATH Grand Island Yaa ❑ Hall 9. RESIDENCE -STATE BC COUNTY Bc QTY', TORMOR LOCATION 90 StgEET ANO NUMBER rMdvzv CaMr1 I* INSIDE CRv'_*M Nebraska Hall Grand Island 1910 E. Phoenix 68801 i Y,a No ❑ 10 RACE - IaA - VAW. j_y AmmucMFes^ II ANCESTRv*q xYBn. NW-cw CiFrrnFn. Mrl 12 ®MARRIED ❑WIDOWED tJ NAME OFSPOUSE IfMegww41*nnwW skIS0600 White O`N ISI American NEVER DIVORCED. Lester Chambers 14 USUALOCCUPATION rr,A. A1IIlyd.a« ow omv 1w 11 I.b IIMD OF BUSINESS WDUSTRY 115 EDUCATION ISOac4oNY canPlaYA d IHY01A - e r 0121 omae Domestic trO COYpa n.Aa O.1 16 GATHER - NAAi - •. PRST .... MIDDLE - LABT - - - tT, MOTHER FIRST MIDDLE MAIDEN SURNAME John fred Power Rose Nellie Trainor 16 WA5 DECEASED EV A -114 US AREAED FORCES' - - - .. _ tw INFDAYANT • NAIN .. - Ira. ro ar IAtA l ( d Ya. 4» w aI10oAln a aaIVILAa1 No !. - - -- Lester Chambers 190 INFORMANT ADDRESS .. - ..STREVI- RRf&NO.CITY OR TOWN STATE -ZIP( 910 E. Phoenix, Grand Island, Nebraska 68801 20 R- S*NATUR &LICENSENO 21. METHOD OF DISPOSIT;ON 210 DATE : 121C CEMETERY ORCREMIATOW NAM( �Gc L� o`�tcE.•,e� */143 W� B'W ❑Re—a, j May 6, 2003 i St. Joseph`.: _Catholic Cem. '22a FUNERAL HOME -NAME 121-6 CEMETERYORCREMA70RY LOCATION Ci1�Off 1JVM STATE Livingston- Sondermann F.H. °° °'" i York, Nebraska _ 220 FUNERAL HOAK ADDRESS (STREET OR RF 0 NO CITY OR TOM STATE; ZIP) .... - 601 N. Webb Road, Grand Island, Nebraska 68803 -4050 23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE- PER LINE FOR 'n, b, AND IUI - IMSrval usOYdo mrsl An] EeaV+ RAPT r 4� >r I If0e r4f ` —DUE TO, OR AS A COkSqDLIENCE OF q.. _.. .. 1me�. aI d+It•rr: Ceat'I DUE TO OR AS A CONSEQUENCE OF - -" °I'.EIwM' 11ai! �':: 1' "• - .. OTHER SIONIFCAN? CONDITIONS -CwX1*0. COlNInb10119b TE aern t.A nq'FYnEO TPART mIF TEMAIf WAS THEREA .%1 AUTOPSY WAS ..��REFERREII SC MEDIiit PART 'PREGNANCY IN THE PAST 3 MONTHS' YAAMhf,i OR COR(NER% 1 I lade va �C 6-0 (OJxr }• Q4, E J I/CYu ! IAges'J'hAi YES ❑ �' ❑1 res ❑ r16a , 2100 DATE OF KILOV 140 DAY Y.) 1260 HOUR OF INJURY 126d DESCRIBE HOW INJ. -Y O fu-KO 1 J kec w UMW-40 l + na C�M Su cde Pe" . He INJURY AT Ism SD EpI facto" 26Q ?fp LO CAl10h - SREE :� -nuF D O —77, OR . TOWN STATE f n HIInKIfF IneesF9AlIO�� Yas No❑ f— } — - - 2ta DAIEOF�IH ;Ab �NIr nI .:. .. •.,. °y - _ UA7F 51GNE0 Ik: ita, - i100 IVN1I# DE6tM .- 4. r ^.�.27D DAi 9&&b (w DAt' Y •- �?TC tBAETJQF "OEA:H - - 2Bc- NIRONOUNCED f>EA:i K' M frPRONOUNCEU DEAD PN.I.r 2'7,0 To pIA Oar al TF LrgMIQOyE daNrl OCtM r Ita IIIIIl. r f100ue 10 FIS • f ° 28e On m W.n Q ham.vlro�.,�r. "ry w•vff*q..on -'N 00-.0 ado' YcuIAO r ►YCaIRa1.l a1.IW / the r.'�E OrA Y10 yYN a aAl aue to a1a cAUa.IS1fYM0 .. 29 DIO TOBACCO USE CONTRIBUYE 70T IDEA N+ HAS ORGAN OR IISSUE DONATION BEEN CONSIDERED' _kv AdAsCONSENTGRANTFO. - 1 ❑. 'TES ® NO ❑ UNKNOWN - ❑ YES - ® NC J.. ❑ YES' ® NO 31 NAME AND ADDRESS OF CERTKIER ,PINVSICtAN. COPA)NER S PHVSICNN OR COUNTY ATTORNEY. Ice a Pnnl; Cxt �u 1. Sc ! h'e ►►►. e 2 II fs t-!i' . F"Na �d lc ti w YCd �'^rci ✓1d Ts (u..id. A/ t i ICC 3 -- J2A REG15T ' :17' DATE FILED BY REGISTRAR 111110 A.Y YI -�� - - MAY N. vvvry It