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WHEN TENS COPY CARRIES THE RAISED SEAL OF THE NEBF ASKA HEALTH AND HUMAN 3EBW~.^t. SYSTEM, R CERTN~S TIC BELDW TO BE A TRUE COPY OF THE OR/O/NAL RECORD OIIEE~'~ ~ ` -=~ ___ r' THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTL~N;-N~Ff I$= ~-__ • -''~ THE LEQAL DEPOSITORY FOR VITAL RECORDS - = =~ L~ DATE DF/SSUANCE 2 o i o 0 0 o s 3 =°~°-~ w ~~- -~ =- OCT 2 6 1999 ass~sTANT sr~:rL~i~E~isTR~A~-J ~ ~~ ~_ 4 LINCdL11~ NEBRASKA HEALTH AND HUMAN SER~ICE$ S.~!STEA~ _= - STATE OF NEBRASKA- DEPARTMF.l~T OF HEALTH AND HUMAN SERVICES FWANCE~AND~i3PPOItT -T,. ~- 4 VITAL STATISTICS - _ - CERTIFICATE OF DEATH L DECEDENT • NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH IMOn7h, OaY. Yea I _ Joseph M. Avery ~ Male October 15, 1999 4. ,CITY AND STATE qF 91RTH ))loaf M US.A., name Comhy/ Sa. AGE - La51 Birthday UNDER 1 YEAR UNDER 1 DAV B. DATE OF BIRTH /Mdnah. Day. YBarJ Grand Tsland, Nebraska (Vra, 7 1 56. MOS. I DAYS 5c. HOURS' MINS. 7~ne 15, 1928 `I 7. SOCIAL SECURTIY NUMBER Be. PLACE OF DEATH 505-30-5477 HOSPITAL: ~ Inpaiant gTHER: ^ Nursing Home Bb. FACILITY -Name 111 not insfitunon, give aa'Bef aM number) ^ ER putpatlent ^ Residence --.:oi:.~=Fralli:lS id~lcal ~ertter ^ DDA ^_QtnQr/SgacrlYi_._..~__.-- - -- CI7V. TOWN OR LOCATIpW OF DEATH ~ ~ ~ 8d. INSIDE CITY LIMITS 9e. COl1NTV OF DEATH . _ - Yes XQ Na ~ Hall _.__ Grand Island 9a. RESIDENCE -STATE B6. COUNTY St. GITY. TOWN OR LOCATION 9d. STREET AND NUMBER lhrcludirg Zrp Cage/ 9e. INSIDE CITY LIMITS Nebraska Hall Grand Island 1515 E. 7th St. 68801 Yee © No ^ 17. RACE • (e.g., WhUe. Black. American kltlian, 11, ANCESTRY leg.. halian, Mazican, German, etc) 12. ®MARRIED ^ WIpOWED 13 NAME OF 3Pg115E /I/ wile. give maiden name/ etc.) ISpecity~ ISpec~tyl ^ NEVER ^ GIV0RCE0 Irene E. Peterson YYl I ~- to Amer a" G"an MARRIED t4a, USUAL OCCUPATION (Grua kiMdWOrk ddwa during mpsr 14b. KIND OF BUSINESS INpUSTRY 15. EDUCATION ISpeCity only hignesl grade completed) dwOnr /iA9,evener ! E~ SIy 10-12) College i1-4 o. 5•I ~rar-erJoperator Pool & Spa Company L ~ _.___.._ 18. FATHER .NAME FIRST MIDDLE LPST 17. MpTHER FIRST MIDDLE MAIDEN SURNAME George _~ Aver Get t i.e `May -- Keller 10. WAS DECEASED EVER IN U.S. ARMED FORCES? -- __ _-- _ _ 19a INFORMANT - KALIF (Yes. no. yr unk.l I II' as, ve er dales d services) Yes: Vu~rv !~~ ~-~ 46 12-7-4$ Trene £•.. Avery 19b. INFORMANT MAILING ADDRESS (STREET pR R.F.D. NQ., CITY OR TOWN. STATE. ZIP) 5 E. 7~"- St. , Grand Island, NE. 68801 ___ _ _ _ ' ~20. EMBAL ER . SIGNnTURE d LICENSE NO. ' /y ~ ~ 21a. METHOp OF DISPOSITION 21b. DATA{ ~ 21 C. CEMETERY OR CREL!ATORv ~ N7 ME f f r. ® Burial ~ Removal ~ Oct . ~.(:;; ~-.-__ 19, 1999. Grand Island Cemetery __ ^ .a FUNERAL H~ NAL'E f 2+d. CEMETERY OR CREMATJRV LOCATION CI?" . R TOWN STATE ^ Cremation ~J DonaUCn ! Apfel-B_utler--Gedde: rand Island, P~ebraska~ . - L - ~--- --- . --- - 22b FUNERAL HOMr ADDRESS ISiREET OR R.F.D NO.. CI7V '1R TOWN. STATE. ZIP( 1123 West Second, Grand Island, NE. 68801 IMMEDIATE CAUSE TENTER ONLY ONE CAUSE PER LINE FOR Ia1. 16~. AND Ic11 I Ingerval between onset and deem _... ... r _ .. ._- __ pVE TO, OR AS A CONSEQUENCE OF'. 1 Interval between Onset end naam = ~t S ~~rro~~y ~.~1 s %- -- - - ~ ~ y~ Dl1E TO, OR A$ A C0145EODEi1CE DF; I Interval between onset and deem I (c) ~ PART OTHER 5K3NIFK;ANT CONDITIONS - CandNOns Ctlntn6ufing b the death 6W opt related PgRT III IF FEMALE. WA5 THERE A 24. AUTOPSY 25 WAS CASE REFERREb TU MEpIC ~{L PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER H _ (Ages 10.541 Yes NO Y0a No Ves NO 28a. 28b. DATE OF INJURY (MO., Day, YcJ 28c. HOUR OF INJURY 26tl. DESCRIBE HOW INJURY OCCURRED ACndent ~ Undetermined M Suickle ~ Pending 26e. INJURY AT WORK 261. P CE F INJURY - t ho , )arm. street. lactory 28g. LOCATION STREET OR R.F.D. N0. CITY OR TOWN STATE o~ ce tw~eing, etc. / Homicide Investigatiyn yes ^ NO ^ 27a. DATE OF DEATH /Mo.. bay, Yr/ 2Ba. DATE 513NE0 /Ald.. Day. Yr.l 28b. TIME OF DEATH •s~ ~U`•l~-g'Cf a~1g'~ M ~i 276. GATE STONED /MO.. Pay. Yc) 27c. TIME OF DEATH ~ C 28c. PRONOUNCED DEAD /Mo.. bay. Ycl 28d. PRONOUNCED DEAD (Hours ~ ~~. ~~37 ~€~ _ M M _ a 27d. Ta the heel M my krgwladge. th urred at dre r. , tlate a pla and dye Itl U1e ~ ~ 2Be. On Use Dade W axeminafdn aM/Or IMeeUgelion, in my opinion death occurred al Causelsl staled: ~ 6 U1e time, date and place and due to the causelsl stated. 51 nadxe and Title) ~ 5' nature and Title 29. DID TODAY-~7 p~ CONTRIBUTE TO THE DEATM7 u 3ps HAS ORGAN OR TISSUE DONATION BEEN CON510ERE0? 30.b WA5 CONSENT GRANTED? Y • 1 YES ~tJO ^ UNKNOWN ^ VES ~ NO ~"" ^ VES ~ NO T 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Typo q. Prinll David R. Co1an M.D. 729 N. Custer Grand Island, NE. 68803 32a. REGISTRAR ,~ 32b, GATE FILED BY REGISTRAR lMa.. Oav. Ycl