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STATE OF NEBRASKA
<br />:.
<br />
<br />1. DECEDENT -NAME
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMEIV=~"t7~ NE~LTF~ ,4lyp
<br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY pF THE f~IG~i~11': `• ~L`C?Rb. 0"N ,
<br />FILE WITH THE NEBRASKA DEPARTMENT OF MEALTH AND HUMAN SERVI(~~ES;,;VIT, r~~~ DS r
<br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. ,.•~ ~j' ~ •.
<br />DATE OF ISSUANCE „..~~ '! ',
<br />MAR 0 5 2010 ~ O ~ V O ~ ! J Q S~LEY . ~'&IOPER; • -' ~ r
<br />;455•fS1rA SATE "REGISZ`R:4R. ,-
<br />DE~,~ft•TM~NT OF HEALTF'L'AI~(D
<br />LINCOLN, NEBRASKA HUM.~IV'Sr~~E$ry~r +~" .~ r.d '
<br />S7A7E OF NEBRASKA - DEPARTMENT OF HEALTH `y~.S' R
<br />BUREAU OF VITAL STATISTICS ~ a Vr~r~
<br />~.~.
<br />CERTIFICAtE bF DEATii~ ~; ~~> :, .,., ,, "'
<br />FIRST MIDDLE LA5t ~2. SEXY 3, DATE OF DFJITH (aeprlh. Day. YaK/
<br />Truman Dale Short :iale May ]., 1991
<br />~. CITY A, STATE OF SIRTI I (M n:: ;n U.5.A.. namR Counbyl 5a. AGE • Last SiMday 8. DATE OF BIRTH (awrlrl, Day, 11,ar/
<br />(Yrs 1 56. MOS. DAYS 5c. HOURS MINS.
<br />~ King City, Missouri ~~ 83 Jul 10, 1907
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE CF DEATH
<br />H~y^P1TAL: ^ Inpatient ~ ER:QUtpnn9rN G p0A
<br />506-01-13Q0 TH R: l/~NUn{rq Hartw G Reswsnce [i Omer ISMC+ryI
<br />8D. FACILITY -Name (r nnr indfiNflon, pave. aDee1 ann rwmbsr) Bc. CITY, TpWN OR LOCATION OF D ~J,TH 8d. INSIDE CITY UMRS ea. Cpl1NTY OF DEATH
<br />St. Francis Skilled Care Grand Island (es aNOJ Hall
<br />Sn• RESIDENCE -STATE 9b. COUNTY Bc. CITY, 70WN.pR LOCATION >M. STREEI :tND NUMBER (mCWdinp Zlp Cody) ik. a1SIDE CITY LMArTg
<br />.Nebraska Ha11 Doniphan _ P.O. Box 150 -(spe~es "'~,
<br />10. RACE • (R.q., WniN, Black, American Indian, t t. ANCE$TRY ta.q.,6alrarl, Mexioen, Garman. atc.l 12. MARRIEO,NEVER MARRIED, f 3. NAME OF SPOUSE (N rrnaa, prva maiden nanny
<br />.x.~i~e ( HI WI ED, QIVO ED (~ ily/
<br />naaa. American q~ [l~arriec`~ Marjorie J. sliger
<br />fAa. USUAL OCCUPATION (hive Kind d a'drk ddns during mast top. KIND t>F BUSINESS INDUSTRY
<br />a Iaprkilp IAa, eve d rroredl r., ( ~ EhmerxarY$ ~~Y ID-T21 i CQMpe ;1~ a s•I
<br />Eensite supervisor 0b. ASCS Office Q~
<br />18. FATHER -NAME FIR37 MIDDLE 1 ACT ~ 7 unr.aan ....rneu ...ue
<br />IYes. no, ar unk.J Id yar, give war And dates d serncaal
<br />RIAL. Cramaepn,RemdVal, 20b DATE
<br />Donation
<br />urial Ma 4 1991
<br />E LMER -SIGNATURE 8 LICENSE NO. A rT
<br />A I~ d~
<br />T0, OFl AS A CONSEQUENCE OF
<br />PARTv/,1(,'1/ ~~~~/'r~'~r^nr r:vnUrrruns - c;prgipons cpnUibulirlB tp QAatn puf not retatea
<br />N R~MV~ ~f
<br /><a. ACCIDENT, SuICIpE, NOMIOIpE, I:NDET., 28b. DATE OF INJURY (Mo..pRY. Yr.) 2
<br />OR PENDING INVE5TKiA71pN ($p-cily)
<br />k INJURY AT WORK 281. PLACE OF INJURY • M Ilprne. (arm, atraet, facbry,
<br />lSPecdY vaa a Hdl oAice 6udanq. etc. ISP~~i'l
<br />PART III IF FEMALE, WAS THERE A
<br />PREONANCV IN THE PAST 3 MONTHS.
<br />Yes ~ No G
<br />HOUR OF INJURY 28tl. DESCRIBE HOW 1N.
<br />~9
<br />FIRST MIDDLE
<br />Susan ---
<br />(STREET OR R.F.D. NO.. CITY Oq
<br />Boni h NE.
<br />20d. LOCATION CITY
<br />J
<br />AEET OR N.F.D. NO.. CITY OR tOM
<br />I kNS/rvN DwwMn goal and tlaaaf
<br />eSferYal 601waan CSget and tTaaln
<br />I
<br />i
<br />1 _
<br />~~•InlaryN 60hrreen OfIIM and dMlf1
<br />1
<br />2a. AUTOPSY K. WAS CASE REFERRED TO MEDICAL
<br />I Yes a Wn/ EXAMINER OR CORONER?
<br />? ~~ r"SPeo/Y v..~or ~/
<br />R.F.D.
<br />cn Y uH t VWN STATE
<br />- - ~ -- ~ ~ ~ ~ ~-' ~""' 28R. DATE SIGNED (Ma. Day, YrJ 2tlb. TIME OF DEATH
<br />r~~
<br />27D. PATE SIGNED 1~~. DRY Yr.1 27c. TIME pF DEATH ~~ ~ lac. PRONOUNCED peAD (AID.. DRY, Yrl 28d. PRONOUNCED I
<br />i 27d. To tlN Deaf Of my k/bw{Klge, death pccw:ad at f!M tim., dale arW place and eue b ~ Q ~ P9e. pn me Dayia pl s>,ammRUdt Rnd nor ,nVM1paU0n, ~n my ppngn dtR1h
<br />[[ auaRla) Haled. /) ~ r ~ $ s fne Irma. date and pM[e and dw fc dra tweets) staled.
<br />true and rids / t/Mlr1`~n"~i s atone ana ri11e
<br />DID TOBACCO USE CONTRIBUTE 70 THE DEATH? 30a. HAS ORGAN OR TISSUE DONATION BEEN CONSIpEREp~ 30b WAS CONSENT GRAN7Ep?
<br />q YE5 ~10 ~ UNKNOWN 17 YES ENO :~ YE5
<br />TAME AND ADDRESS OF CERTIFIED IPHVSICAN, CORONER'S PHYSICAN pR COUNTY ATTORNEYI (Type p Prvnl/
<br />A. Morse M.B. 725 N Custer G d I l d
<br />19. INFORMANT -NAME -MAILING
<br />Mar 'orie Short'
<br />20c. CEMETERY OR GREMATQRY -NAME
<br />Juniata C m
<br />22. FUNERAL HOME -NAME AND ADORE
<br />U5E PER LINE FOR (al, (6j, A1dD Icll
<br />/llDyrl
<br />r
<br />NO
<br />~ ran s an , NE. 68803
<br />326 DATE FILED BV REGISTRAR /Mo.. Day, YaJ ;t
<br />.. ~ .. ~..__ _ MAY .~ i99f
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