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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CEKTIFIES THE BELOW TO BE A TRUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH TS THE LEGAL DEPOSITORY FOR
<br />VITAL RECORDS. --- -~- -
<br />2oioo3~1~ ___- - _--_
<br />DATE OF ISSUANCE -~, -_ ---~, ~ : _•
<br />-- --
<br />~UN 2 4 ~ STANLEY S~ ~~~~ER.~ ~zxgcRr
<br />LINCOLN , NEBRASKA BUREAU OF ~`PA~ ST`t~iTl$T~~~=
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CF_RTIFICATE OF DEATH /-,, "3 ,~ r •~
<br />1. DECEDENT-NAME FIRST MIDDLE LAFiT 2. SEX 3. DATE
<br />4. CITY AND STATE OF BIRTH /h ndt In U.S.A., name CCUrtvYl
<br />.-..i
<br />7. SOCIAL SEC RITV NUMBER !~~ F
<br />W. FACILITY - Nsrtw IM nd iroteutbn, prw amrst ertd n 1
<br />ISt. Francis Medical Center Grant
<br />ge. RESIDENCE • STATE 8b. COUNTY ac. CITY, T(
<br />.Nebraska Hall Doni
<br />10. RACE - (e.p., WhM, Black, Ameriean Inelen, 11. ANCESTRY (e.g.,ltelian, M etlicen, Gam
<br />etc.) (spotty) lswCilyl (O
<br />b
<br />White American
<br />148. USUAL OCCUPATION /Glue kind d work don e dunrtp mpar 116. KIND OF Bl
<br />d working Ida, even Anend/
<br />'•13
<br />Farmer Cattle Feeder x A ricu]
<br />16, FATHER -NAME FIRST MIDDLE LA!
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES7
<br />IVes, nd, w unk.l IH ya, plw wa ens ewes dt eervicesl
<br />No
<br />12. MARRIED,NEVER MARRIED,
<br />WIDOWED, DIVORCED (SpeciryJ
<br />011
<br />IOTHER -MAIDEN
<br />NAME-
<br />8. DATE
<br />~. Ysarl
<br />ty, Ye1r/
<br />Sd~ INSIDE CITY LIMITS
<br />lS-eciry Yef w AbJ
<br />Xes
<br />AND NUMBER (Inchalrg
<br />S U.S. Hwy
<br />13. NAME OF SI
<br />menury dr 5eCCMery 10.121 I
<br />l2 _
<br />I
<br />FIRST MIDDL
<br />31ee T -
<br />ISTREET OR R.F.D. NO., CITY
<br />F DEATH
<br />9e. INSIDE CITY LIMITS
<br />IJVeciA' Yse w AbJ
<br />No
<br />piw maiden nuns)
<br />Omer
<br />College 11.1 w 5.)
<br />1 u5T
<br />20e. BURIAL, Cnmeebn,Removsl, 20A. DATE 20c. CEMETERY OR CREMATORY -NAME 20d. LOCATION CITY OR 1UYYN S t n t t
<br />'al June ~, 1993 Cedar view Cemetery Doniphan, Nebraska
<br />i 21. EMBAL ER -SIGNATURE 4 LICENSE NO. '~~ (~~ ~ ~~ FUNERAL HOME • NAME ANO ADDRESS (STREET OR R.F.D. NO., CDY OR TOWN, STATE, ZIPI
<br />7 Apfel-Butler-Geddes 1123 W 2nd Grand Island, NE 68801
<br />IIAMEOI~ A S ` (ENTER ONLY ONE CAUSE PER LINE FDR Iel, Ibl, AND IC11 i Imerval between onset end death
<br />PART
<br />_' MASSIVE CRANIQCEREBRAL TRAUMA INSTAtI'T
<br />OUE 70.OR AS A CDNSEOUENCE OF. I Imerval !»Iween anttet end deem
<br />I
<br />I
<br />I _
<br />._ Ibl _-, _.- ,
<br />"DUE TO,'OR AS A CDNSEWENCE OF: ~ ~ ~ 1 InurvW netween onset and death
<br />I
<br />1
<br />OTHER SIGNIFICANT CONDITIONS - CbndNlene comribuling to death 6u1 not retpted PART III IF FEMALE, WAS THERE A 21. AUTOPSY 25. WAS GAS6 REFERRED TO MEDICAL
<br />PART PREGNANCY IN THE PAST 3 MONTHS? (SpeCly Yee w No) ExgMINER pR ~1RONER?
<br />n vee ^ Nb ~ NO /~
<br />28a. ACCIDENT, SUICIDE, HOMK%IDE, UNDET.. 29b. DATE Of INJURY /MO..Day, Yc1 28C. HOUR OF INJURY 28d. DESCPoBE HOW INJURY OCCURRED
<br />OR PENDING IHVESTIpAT10N (speaiy/
<br />ACCIDENT .TUNE 1, 1993 1600 HRS FELL OF A LADDER ABOUT 12 FEET
<br />28e. INJURY AT WORK 2&1. PLACE OF INJURY - At home, lum, ebwL factory, 26g. LOCATION STREET OR A.F.D. NO. CITY OR TOWN STATE
<br />/Speriy Ye9 w NCI oldae buibirtp, etc. (SP+ciNl
<br />Yes )SOME 11525 HWY 281 DONIPHAN NE
<br />27e. DATE OF DEATH (Md.. Pay. Vr.1 28a. DATE SIGNED /Mo.. Dry, Yr,J 2&b. TIME OF DEATH
<br />- a .TUNE 1, 1993 a
<br />_ 27b. DATE S16NED (Md.. Oay, Yc) 27C. TIME Cif DEATH ~ K Y 28c. PRONOUNCED DEAD IMa.. Oey YcJ 28d. PRONOUNCED DEAD /Hour/
<br />~ .TU1)E 3 , 1993 18 ~ ~
<br />~ 27d. TC tM neat bl my knawl em nd ce ertd due ro the 2Be. On the Deus of exemmadon endow inwetpettCn, In my opinion death occurred et
<br />ceueslel etetW. ~ is me time, date end niece and due M Ste ceuse161 tnetee.
<br />~Si nature ertd 71ne I Si nature eM Tide
<br />29a. DID TOBACCO USE CONTRIBU HE DEATH? 30a. HAS ORGAN OR T~E DONATION BEEN CONSIDERED? 30b. WAS CONSENT G NTED?
<br />O VES NO ^ UNKNOWN YE5 ^ NO VE5 ^ NO
<br />31. NAME AND ADDRESS OF CERTIFIER IPMYSICAN, CORONER'S PHV5IGAN OR COUNTY ATTORNEYI (Type w Print)
<br />Dr. Abraham Riv ra 2620 Fa• ley Ave Grand Island, Nebraska 68803
<br />32b. DATE FILED B~ REGISTRAR /Mo.. Dry, Yr,)
<br />32a. REGISTRAR a -- s
<br />SP. AGE - Laq &rtlx ay .. _._ _
<br />IVre,l Sh. MOS. I DAYS Sc-HOUR I
<br />96 _. I
<br />C"E~OF DEATH HOSPITAL ~ Inpedam ~ ERfDutpedsrn ^ DDA
<br />P D'1'h1ER: ^ Nursing Ha1N C] RnieMACe ^ OdrM /3Wdilyl
<br />umber Bc~ CITY TOWN OR LOCATION OF DEATH
<br />f) /.,~
<br />
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