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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HE,4L7�i�AlV�d .HU�
<br />THE BELOW TO BE A TRIiE COPY OF THE ORIGINAL RECORD ON RLE WITH THE NEBff�1�KA� �EpA�, ,
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR V,I�'��;,d���U
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<br />DATE OF ISSUANCE '
<br />,IA�I Y' � �D�� S7'A�NLEY�S;�`G�JDl��
<br />dCCfCTdA1T (�714'�{"
<br />LINCOLN, NEBRASKA
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<br />M,p�l �SERVICES, IT CERTIFIES
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<br />STATE OF NEB�iASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPI'OF�j`j h: � �},
<br />�`� CERTIFICATE OF DEATH 1 U 3 '�''`
<br />i. DECEDENT'S•NAME (Kitat, � Mlddle, Laet, SuBlx) � 2.SEX �� 3,DATEOF-0E/n�TH (Mo:;��ay;'fr.) ,
<br />Ona Maxine Hawthorne emale December 3't.;201
<br />4: CITY AND STATE OR TERNITORY, OR�FOREIQN COUNTRY OF BIRTH � Ba. A�E•Cest Birthdey bb.�UNDER 1 YEAR bc. UNDER 1 DAV' 8. DATE OF BIRTH (MO., Dey; Yr.)� � �
<br />(Yra.) MOS. DpYB � HOUR9 MINS.
<br />Fullerton, Nebraska 96 March 6,1914
<br />7.30CIAL 9ECUHITY NUAEBER 8a. PIACE OPOE(1TH
<br />5 4 4- 2 8- 3 0 3� ttQSeaet,: � m�at�ens �- 0-��� rromen.TC ❑ Ho�e� Fac�n�y
<br />Bb. FACILITY-NAME pf not inatftutlon, give atraet and numbef) Q ER/OUlpaGent CI DecedenfeHome
<br />St. E'rancis Medical C�nter ❑ oao vo+n�ca„�,�
<br />8a CITY ORTOWPI OF DEATH (Include Zip Code) Bd. COUN7Y OF DEATH ,
<br />Grand IslanB 68803 Hall .
<br />Ba RESIDENCESTkTE Btr. COUNIY 8c. CI'fY ORTONM
<br />Nebraska Hall Grand Island
<br />8tl.9TREETANDNUMBER Be.APT.NO Bt.LPCODE
<br />2547 W. 4th St � 68803
<br />10a. MARITAL 8TATUS AT TIA4E OF DEATH 0 Manied ❑ Never Married 10b. NAtdE OF SPOUSE (Firat, Middle, Last, 8uflix} If wite, give maiden neme.
<br />O Mercled, but separated � Widowed ❑ Divomed O Unknown , E1I��. Hawthorne ( Dec )
<br />Bg.IN31DE CITY LIMITS
<br />{� YES 0 NO
<br />11. FATHEH'S•NAME (Firet, � Middle, �. Laet,' �� �Suffix) 12. MOTHHR'8-NAME (Firat, Mlddie, Melden 6urname)
<br />Amos G llaqher Emma Viola Jackson
<br />13. EVER IN U.S. AflMED FORCES7 aive detea ice I ea. 1 NFORMANT NAME 14b. RELATIDN9HIP TO DECEUENT
<br />(ves,no,orunk.) NO C rj.$ Hawthorne Grandson
<br />15. METH00 OF DI3POSITION 18a.E � ER- E tHb. UCENSE N0. 18c, DATE (Mo., Day, Yr. )
<br />;�BUrial q Donatlon
<br />❑ Crematlon ❑ Entombment 18d. CE ERY, CBEMATORY OR 0 ER LOCATION CITY /TOWN STATE
<br />ORemoval DOther(BpecMy) � u erton� Cemetery Fullerton �. . NE
<br />17a FUNERAL HOME NAME AND MAIUNa ADDRE9S (Streat, CltyorTown, Stele) 17b. Zip Code
<br />Palmer Funeral Home, 2'10 Irving, P.O. Hox 332, Fullerton, NE 68638
<br />18. PART I. Enter the analn of avema-diseaeea, InJwiea, or complicaUons-that direcUy caused tha death. 00 NOT enter terminel events auch ae cardiac aneat, � APPROXIMATE INTERVAL
<br />respiratory erreat, or ventrlcular IlbrmaUOn wMOUt showing the eUOiogy. DO NOT ABBREVIAIE. Enter oniy one cauae on a Iina Add fldditionel Iinea (f necessery. �
<br />IMMEDUQE CAUSE: � onsat ro tleath
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<br />m1MEDUl1ECAU8E(Fhml • f� �-+ � V i C.✓ �'^y �
<br />�°���°�8 DUETO,ORABACONSEWENCEOR t oreetrodeeth
<br />indeath) , . . . '. I
<br />se��urnss�u�o�,h ro) p{f�tca..fYt GY�AO�-� ; c�.c� S
<br />���g���� DUETO, HA9ACONSEQUENCEOF. � � � I onseltOdeath � �
<br />on INe e.
<br />ENertlteUNDEHLYINGCAUSE �
<br />(dlseaworinJurythetlnWeted � (�) . � . . . . . �
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<br />������) DUE70,ORA6ACONSEQUENCEOF: i onsettodeath
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<br />18. PART.II.OTHER 91�NIFICANT CONORIONS-Coml�lone contdbuUng to the tleath but not reeulling in Ne underlyit�g caUea given In PAqT L� � i B. WA3 MEDICAL EXAMINER
<br />J �� Q OR CORONER CONTACTED7
<br />{/1/1. �(,�(,d/J�, � {�M.�� �GLOL� �OVY` ❑ YES �_ NO
<br />20.IFFEMALE: 21a EROFDEATH 210.IFTRANSPORTATIONINJURY 21C.WA9ANAUTOPSYPERFORMED7
<br />� Not pregnant wiihin past year �el�ral ❑ Hanidde O DriveNOperator . .
<br />❑Passenger � ❑ YE3 �NO
<br />❑ Pregnent at time of death ❑ Aocident0 Pending Inveatlgafion �
<br />❑ Not pregnant, but pregnemwithin 42 deys ot death � � P ��� 21d. WEREAUTOPSYFINDINQSAVAILABLETO
<br />0 suicide ❑ Cou�d nM be determined � p�her (Bpeclly)
<br />❑ Notpregnan6 but pregnent 43 daye W 1 yeerbefore death COMPLEfE CAU9E0F DEATH?
<br />0 Unknown fl pregnent within the past year � � � �❑ YEB ❑ NO
<br />22a. DATE.OF fNJURY (Mo.,�Day, Yc) 22b. TIME OF INJURY. 22c. PLACE OF INJURY At home, ffirm, atreet, tectory, Whce building, wnewctlon site, etc. (SpeCtfy)
<br />m ----=�__,�_-
<br />�� 22e.DESCRIBEHOWINJURYOCCURRED� �
<br />0 YES ❑ NO
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<br />22f. LOCATION OF INJURY • BTREET & NUMBER, APL N0. CIiYrtOWN
<br />.a�� �. .�, . . .
<br />23s. DATE OF DEATH (M ., Day, Yr.
<br />�� ra 3 3ato
<br />�� 23b,DATESIG ED ( .,Day,Yr.) ' 23c.T1'
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<br />23d.To tha tiest of my awledge, death occutted at the
<br />o � anddue thecauae(s ated. (Slgnefureand7l�
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<br />26. DIDTOBACCO USE CONTRIBUTETOTHE DEATH7
<br />O YES A�NO ❑ PROBABLV ❑ UNKNOWN
<br />NAME,TITLEANDADDRE FCERTIFIER (PHYSICIAN,C
<br />�°b��CCC. S •J-�-Gcr1JG�, 1�`(.�
<br />28a.RE0I8TRAWSSIONATURE� � . f
<br />56UE � . .ZIPCADE
<br />� �� � ���. 24a.DATE8IQN8D(Mo.,Dey,Yr.) 246,71MEOFDEATH
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<br />PDEATH' ��� , 24c.PRONOUNCEDDEAD (Mo..Dey,Yc) 24d:TIMEPRON0UN6ED�EAD
<br />.C70 ��n �ma� m
<br />dete end place 5�� 24e. On the bas(s o1 e�minat(on amilor inveatigedon, ln my opinlon death occurred et
<br />'- �� � p o � the Ume, daie antl place and due to the cause(s) etetad. (Signature end 17t1e )♦
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<br />28a. HA8 OROAN OR TISSUE DONATION BEEN CONSIOERED? 28b. WA3 CONSENT 6RANTEO?
<br />❑ YES NO Not Applfcabl,e H 26a Ie NO 0 YES NO
<br />VER'9 pHYSICIAN OR CO[1NTY p1TORNEY) (ly e or Print) .
<br />aU1� �U. ��c ��or9 d , A!E Cog�
<br />I 28b. DATB FILED BY REOISTRAR (Mo., Day, YrJ
<br />�, ,q. JAN Y � 20��
<br />HHS-s� ilioa�ssasl�
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