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<br />
<br /> WHEN THIS COPY CARRIW THE RAISED SEAL OF THE NEBRASKA BTATE DsPART4f.;NT OF=MEALTH,
<br /> 1r0MT/F/E8TH!' BECOW TO AE A TRUE COPY OF AN ORIGINAL RECORD OII FFILf-wrif Tor.27 4TE
<br /> DFPARTMLJNT OF HEALTH, BUREAU OF VITAL STAT/STIC$..WH/CH IS THEL QA A 7 COf1 Fi~F ,
<br /> ,VITAL RECORDS...
<br /> DATE OF ISSUANCE
<br /> ....NOV. , 81996 _ : xA Er ~r X00
<br /> 200908$,77,
<br /> ASSIa~TAN7K$ T'E. R&IST6AR
<br /> - , _-._LILUCOClY,. wIEBRASKA - - NOORaSKA ARtNWr-d9~r4Akv
<br /> STATE OF NEBRASKA DEPARTMENT OF HEALTF
<br /> BUREAU OF VITAL STATISTICS
<br /> CERTIF.ICATE:,QF DEATH
<br /> 1. DECEDENT- NAME FIRST MIDDLE LAST - 2. SEX 3. DATE OF DEATH /hfpnth, pay. Year/
<br /> John Richard Miller Male November 3, 1996
<br /> 4., CITYANQ STATE OF BIRTH' tdrtdtdn USA.. nsme equnrry/ 5&' 9GE • Lea161Md0V ` . UNDER' I Y, -AFII UNDER 1 DAY B... DATE OF BIRTH (M-M-'Day- Year/
<br /> (Yrs.( '51) . MOS bAV$: 57 HQURSMIN$::
<br /> Green City, Missouri .
<br /> lQeaembex -7. 1934
<br /> 1. SOCIAL SECURTIY NUMBER 89." PLACE40F DEATH
<br /> ■ „505--38-61$6 ;'.HO§PITAL Inpatient OTHER' Nursing Home
<br /> 6b: FACILITY • Name 10nottmsf,4f cn, pivoatrrpir,andra"MW) © eR'9Wpallgnt Reagents
<br /> ■ Bryan ' Memorial HoS ' Lt al DOA ' Other (Specllyt
<br /> ec C1TY.,TOWN OR LOCATION OF DEATH SO INSID; CITY LIMIT N. COUNTY OF OPwATN
<br /> Lincoln Yee R1 No Cl Lancaster
<br /> Pa. RESIDENCE. STATE 9b,:000NTY 9c. CITY, TOWN OR LOCATION 9d. STREET AND NUMBER (lnckrdlng 2ip.CWtl/ INSIDECITYLIMITS
<br /> NebraHall Grand Island 238 N. CareyAve. 68803lie,
<br /> Yes No
<br /> 10. RACE te,g , Whlta. Black. American IOdlan 11. ANCESTRY Ia.g.. Kahan, Mexican', Garman atcl : 1 MARRIED (^'7 WIDOWED 13, NAME QF,4Pg1JS5 ' N pwe -%oan 41" '
<br /> atc.llSpec.") I$OecNyl 1 L J
<br /> NEVER' DIVORCED .
<br /> 14a, USUAL OCCUPATION tplve'klnd of l * dcn#71Mr7 mpar. 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Speoi onl highest rada OUmplatedl
<br /> ofraibnrirpuUr; even urearMl Elomenrysrr SeortdafY lOd$1' 1 College II-4 or 5-I
<br /> lE 1e ! z
<br /> 1A. 'RA R . MIDDLE LAST MOTHER' FIRST 'MIDDLE MAIDEN SURNAME
<br /> 1
<br /> 'John C mil er (Dec! Nora Fa e Martin Dec.
<br /> 18. WAS DECEASED EVER IN U.S. ARMED FORCES?: Korean Igo, INFORMANT-NAME "
<br /> (Yea, no, pr unk.) (If Yea, give war aryl dates M servlcea)
<br /> 1- 29-54- 11--195 7 Leona M. Miller
<br /> YPS
<br /> 1 go. INFORMANT MAILING ADDRESS ISTAW OR R.FM. NO.. CITY OR TOWN. STATE, ZIPI
<br /> 3 N. are Ave. Grand Island, Nebraska 68803
<br /> 20. EMBALMER -SIGNATURE d LICENSE NO. 21 a. METHOD OF DISPOSITION ' 21b. DATE 21c. CEMETERY OR CREMATORY -NAME
<br /> SWIM ❑Removal 1.? r 6, ,...T.T stlAwn Memorial Park
<br /> a, FUNERAL HOME AME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br /> . 1:1 Cremation ❑ Donation Grand Island, Nebraska
<br /> kit 1 Hgme .
<br /> 22b. FUNERAL SOME APOREES (S- ET OR R.F.O. NO., CITY OR O W N, STATE, ZIP)
<br /> 3213-W-- N . th. Front:.St;..,,--Grrand ;I,slandY Nebraska 68803
<br /> 23. IMMEDIATE CAUSE` (ENTER ONLY ONE CAUSE PER LINE FOR lal.'(b), AND (c)I Interval between onset and dean
<br /> PART / c 1
<br /> (a, I rl- C5, a DUE TO, OR AS A CONSEQUENCE OF'. 1 Int~erv`al between onset and death
<br /> D E To. OR A$ A CONSEQUENCE. OF; I Inlarval between tinsel and deals
<br /> -71
<br /> jo &451
<br /> OTHER $IONIFICAMT CONDITIONS - Conditions contributing to the death but net related PART 111, IF FEMALE. WAS THERE A' 24, AUTOPSY 2$.;; WAS'CASE REFERRED TO-MEDICAL
<br /> PART PREGNANCY, IN THE PAST 3 MONTHS?.. -7 ' tEEXAMINER OR CQRQNE ?
<br /> ' 'Y "~~`r v ~1 e (Agee 10.54) Yes No yes NP ~+r Y. No
<br /> 264. 28b, DATE QF'INJURY (44c)L, bay, Yr./ HOUR OF INJURY 126d.OESCRISE'. HOW INJURY OCCURRED
<br /> 0 Acc4sttl Undetermined M
<br /> 0 Suicide D Pending 26s. INJURY AT WORK 261. PPLAeCE?F, IINNJ'RY -,40,p, farm, street, Iecexy 2691 LOCATION STREET OR R.F.O. NO. CITY OR TOWN STATE
<br /> Homicide Investigation yes ~ NO ~ Ifi 88.
<br /> 27a. DATE OF DEATH %Ma. DAY Yr.) 28x, DATE SIGNED tMo.. pay; Yr.) 28b. TIME OF DEATH
<br /> X November 3, 1996 M
<br /> DATE SIGNED (MO.: Day. Yr.) 27c. TIME OF DEATH - 26c. PRONOUNCED DEAD (MO. DAK Yc/ 28d. PRONOUNCED DEAD tWoud
<br /> 0I6 ly 3.:.03 h1' M
<br /> ~ 2711, To the baN of.my kr(OU w la t,-.01 std dup 1o the ,9 2Sa. On Me battle of aarnlnaeon andror awepegatlon. In my opinion death occurred al
<br /> ,81 * 01 cause(s)stated. / 11 13 me lime, date and place and pee to the ceuae(F)..stated, .
<br /> 51 nature and Tide (7~\. &I naure aD4 nd THIa
<br /> 28.,FIp OBACCO USE. CONTRIBUTE TO THE DEATH? AS ORGAN OR TISSUE DWAS CONSENT GRANTED?
<br /> YES NO UNKNOWN ❑ YES ~NO, 11 YES NO
<br /> AME AND ADDRE$5 OF CERTIFIER (PHYSICIAN, CORONER'S PHYSCOUNTY ATtORNEYI /Type - Prlm)
<br /> 32a. REGISTRAR 02b, . DATE FILED BY RED)STRA . Mp; payY1c/
<br /> NOV P~96
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