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---- WHEN TH/3 COPY CARRlE3 THE RA/SED SEAt OF THE NEBRASKA HEALTH AND H� ��"CC��YJCES - SYS77EIM� tT C�R7rFlES THB BELOW TD BE A TRUE GOPY OF THE ORlG1NAL RE��1Q_�E FKEi��H THE RfEBRAS/Ui HEALTH AND HUMAN SERV/CES SYSTEM, VlTi4L STAT/STtt�':S�ZIDN, iAEFl�fi�� , THE LEGAL DEPOS/TORYFOR V/TAL REGORDS ` �--- DATE O� iSSUANCE � _~ �--�'� "l� �" �U1.17 �� 2 01 �. 0 G� 5 2 - a��c�e�� ASS/S�i{1i�STATE:REG/SFR� - �I LINCOLN,NEBRASKIi HEALTH14NDHUl�INS_fl�G1cS��,y. S�'EM�� - - - `_' - - � _ STA1E OF NEBRASKA- DEPARTMENf OF HF.ALIH AND HUMAN SER��TA� .f E� SI3�ORT ' YLTAL STAT[STTCS ? CERTIFICATE OF DEATH u �' �� 2 0 ��`� � - � i __ i. DECEDENT • NAME � FlflST hatODlE . LnSi � � 2. SEX ' � , 3. DATE OP OEA7H ,Hroi,m. pay. Yead Dona]-d Ra Alexaxider Male June 27 2042 4. CITY AND S7ATE OF BIRTH lNnpt fn t1,SA. neme courttry) 5a. AGE • last 8irthtlay UNDER t YEAR UNDER 7 DAY 8. DATE OF BIRTN fMOnC�. Oay. �ear1 - (Yrs.l Sb. MOS. 0AY5 Sc. NWRS' MINS. Grand Island l�ebraska ' ' November 26 1928 7. SOCIAL SECURTIY NUMBER 8a. PIACE OF DEATH � � 506-28-7826 H��T�- ��P�«eN OTHEH: � Nurs+ng Home Sb. FACIUTY - Na� (Nrw! insfrmtipn, yive sveet artd namberJ � ER �OutpatleM � Fes�dence St. Francis Skilled Care Unit ❑�a � o�,a�,s��<<Y� Skilled Care 8c. CITY. TOWN OR IOCATION OF OEATH ' � 8d. lNSIDE CRY UMRS Be. CAUNTY OF OEqTH � V1.CLLi�,I ��ypll{„( Yas a No ❑ 11Gi�1 9a RESfDENCE- STATE � 9b. COUNI'Y 9c. CItt.70WN OA LpCATlON 9A. STREET AND NUMBER llnc7udrtgZip Code) 4e. INSIDE CITY LIMIiS Nebraska Ha.11 1823 W. 1 st St. , 68803 Y� � No ❑ 10. RACE • �a.g. White. Black. Artrericgn Indfan, 71, ANCESTRY IB,g.. ltalten. Meuicen. Ge�mae, etc� 12. � MARRIEO � WIDOWED 13. NAME OF SPpUSE �ft wde. give maiden nameJ etc.i f5aecihll lSpec�yy) � NEVER DtVOCtCE9 �7�-tE�' Atll@L'1 �nA R G�r�� 14a. USUALOCCUPATtON lGlveklnd07wakdatadurirrgmost 14b. KtN�QF6USiNESSiNDUSTRY 15. EDUCATION �SpecifyoNynighestgradecomDle�li ot IHe,avenilrefiredl Ete mSecurtaary 10-�2) � CaAege It-4or5•1 P.ro�uction Workex Manufacturin L�n"`�mawn � 1B. FATHER-NAME FIRST MIODLE � LAST 17. MOTHER FIRST MIDDLE MNDENSURNAME � - James Farl Alexander Florence 1�fI Scoville I8. WAS DEGFASED EYER IN U.S. ARMED FORCES? 19a IPIFORMAN7-NAME �Yas no. w unk) la Yes. 9ive war eM dates of servicas} No N A M�Y �-�d�' 19b. MFORMANT MAILINt3 ADDRESS {gTREET OA RF.D. kQ CYTY OA TOWN. STA7E ZIPj 1823 West 1st Street Grand Island Nebraska 20. EMBlkLMER - 5 NATURE & L�ENS£ NO. 21a MEiHOD OF D�SaOS�nOIV 27b. OATE � � 21c. CEMETERY OR CREMATORY - NAME � /I�j �,,. {,3 ��;e, ❑ r�,„o„� July 1, 2402 Westlawn Memorial Park Cemei fUNER HOME-N � 21d.CEMETERYOR.CREMA70RYLOCATiON CITYORTOWN STATE K1P_l T1P_ F!]t'1P7'a � Hf�a � G �� O° �� . (_'r�rrl T�l �e-�ri A7a1.v�� e.L-� � �� � �3' t �� i i P � OTHER SlGNIFICANT CONDITIQNS • Cmdi�ona corWibWng to tlie dea@� bu! not relateC PART III IF FEMALE. WAS THERE A . AUTOPSV a:,J WAS CASE REFERRED 70 MEDti �� PflEGNANCY IN THE PAST 3 MONTHS? �t QCAMINER OR CARONER? (Ages70-54) Yes NO YeS No X Yes No Z6a ZBb. OATE OF INJURV jMa. Day. Yi j 26c. HOUA OF lNJUFY 26d DESCRIBE HOW INJURY,OCCURRED � AcCideN � UMetermined � . . M ❑ Suicidg � Pendit�g 2fie. INJURY AT WORK 26f. PL/1C�F� �RY r� mg, tatm, slreeR tadory 26g. IOCATiON STREET OA R.F.O. NO. CITY OR TOWN � STATE a o OfB al% � Fbmicide Lrnesti9� Yes No 2 DATE OR DFATH /MO.. Ddy. Y�J 28a DATE SiGNED 1��. �ay. Yr.) 28b. TIME OF DEATH $ � �li -- � 7' I�o�, � � � M � b. DATE SIGNED /Mp.. Day. Yc) �a TIME OF OEA7H �`� 0 28c. PRONOUNCED DEAD (MO.. Day, Yc! 28d. PRONOUNCED DEAp (HOUq � � Q Y �° Jul 1, 20 .�. 3C� p,/�(. M � w �° M F � . s - �Id To tl�e best W my knowt .�lealh red �ihe ', dat yny place and due to ihe °� x� � 28e. On Uw basis ot eXaminafion a�ttl�or invasfigatian, in my op"vuon death occurred ai �tt causelsl �aced � ~°� Ue time. daae and place and due to tlie cause(sl sfated_ (5' naNre and TWa 3 �neMS and 7itt�e ► � DID TOBACCO USE CO T O E DEATH'� O AN SSUE DONATION BEEN C6NSfDfiRED? WAS CANSENT GF2ANTED? �� YES � NO UNKNOWN � , � YES � � YES �NO ; 31. NAME ANp ADDRE5S OF CERTIFIER fPHYSiCIAN, CARONE ' HYSiCUW OA COUNTY ATTORNEYI lType or Pnnf/ • Sitki. NID 116 a' e Grand Island N�braska 68803 � 32a REG�STpAR ,32b. DATE FILED BY REGISTRAR [Ma, Day, Yr.J i • �n JuL i i 2ao2