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Robert DeRo Herzo Male March 7 1 <br />o NSC . a cm iwn srA� oF a�ani �u �m � u.sa. �e �arrl �- �-��r a onre oF �ar�+ re�m, ner. <br />�Yrs.l Sb. MOS. � DAVS Sc. HQURS� MtNS. R 7 <br />o work ................ York, Nebraska 77 ; ; June 25, 1914 <br />` UC . .......... 7. SOCIAL SECUHiTY NWdBER Ba. PLACE OF DEATH Y <br />m .....�• MOSPITAL: �'1 Inpetlem ❑ ENOulpatlmU ❑ DOA <br />C , <br />� Re�ect ............... 506-09-7497 �❑ r�re� a R�� ❑ a��s�,yi <br />x � B0. FACIUTY - Name (d ���+� 9� �� Rwrrbe�) 8a CrtY. TOWN OR LOCA710N OP DEATH 80. INSIDE CI7Y UN1T3 <br />�SQBCHy YBB W 1Y0� <br />m A ..................... <br />� St. Francis Medical Center Grand Island Yes <br />o ....................... . <br />— 9a RESIDENCE - STATE 8b. COUNTV 9e. C1fY. TOWN OR LOCATION Bd STREET ANO NUbIBER f�� <br />� ....................... <br />�.E Nebraska. Hall Grand Island 1736 S. Arthur <br />w� ........................ �a aace - lae. wnee. e�rx.,Merieen umiae. ��. aucesrar laa.rmaan. Mmacan. cmman. eae.l ,z Mnaweo,�� �aaaweu. �a wwE oF <br />........................ etc.) /�l l�^Deedyl WIDOVYED. DIVORCED ISP�NJ WE <br />° w; White American Married Eve <br />U �' p 14a. USUAL OCCUPATION /fiNe Wid of �t done dim+r9 mos7 tdb. IaNO OF BUSINESS INOUSTRY � <br />Q a G .. . .. . . . .. . . . . ... . . . . . d M�9 C/B. BWBII 8 /BI�78�1 �91�&118/Y Of SB�M <br />�� •-•--••••••••••••••••••• Loan/Finance Officer Home Loan Finance 12th Gra <br />� m 1& FATHEA - NAAAE FlR3T MIODLE LAST 17. MOTHER - MAIDEN NAME FlRST <br />W v� ...................... <br />� � <br />a o J""""""""""""' John D. Herzo Ethel NMN <br />Z lL Z ........................ 1& WAS DECEASED EVER IN U.S. ARMED FORCES7 19. INFORM/WT - NAlAE - MAILINQ AUDRESS ISTREET OR RF.I <br />(Yea �. m wa�.l Ia rea e� war am aazea w serv+ceel <br />�3 w Yes WWII 7-8-42/2-13-46 Evel Herzo 1736 S. Arthur <br />� C ...................... <br />_ �a g�pULL, C�,pempyg4 Zpp, pp7E 20c. C6METERY OR CREMATORY • NAbtE 20A. IOCATION <br />.. D�1 <br />�������������������� �� B 'a Ma.rc 12, 1992 Grand Island Cit Cemeter Grand <br />t� ........................ <br />� 21, - 3I6NATURE UC E NO. 22 FUNEPAL XONE - NAME AND ADDAESS (STREET OR R.FD. N� <br />�""""""""'"""" � L� � Livin ston-Sondermann 505 W. Roeni� <br />a ........................ OOiED1ATE (ENTER ONLY ONE CAUSE PER UNE FOR (al. @I. AND (el) <br />� D ...................-. � � <br />a DIlE TO.OR AS A CONSEOUENCE OF: <br />� . ...................... G �� �� , <br />> ... .................... . <br />� � DUE T0, OR AS A CONSC-0UFNCE QF: <br />O ........................ � w � 7/� d` /��.—� <br />� <br />07HER SIflNIFlCANT CONDITIONS - to Qeath bW ml releted PART III IF FEMALE, WAS THERE A 24. AUTOPSY <br />� � PREONANCY IN THE PAST 3 MONTHS7 / � Y <br />E ........... ..... .. .... P^HT � <br />u ���tM-9.Ow�^^-• rea o nw � <br />.......•..••.......•••.. 28a ACCID9�1T. SYIItYDE. HOMICIDE UNOET, 26D. DATE OF INJURY /Ado,Day. Yr.) 2BC. HOUR OF INJURY 2Bd DESCRIBE HOW INJURY OCCUFREO <br />............_ ........... OR PENDWG INVES'i11iA110N ( <br />.............•..•.••..•. �e. INW!lR11 AT WORK �L PU10E OF IWURY - At Imme. fam6 �re�. facmry. 28& LOCATION STREET OR RFD. NO. <br />... . . . . .. . . . .. . . . . . . . .. . f3P�dl' Yes m Nol � �, e�. f3Pe�fNl <br />Hall <br />�e� se. ies�oe cm unar, <br />(Spedfy Yee a Nol <br />03 Yes <br />/C irile. gtre maiden name) <br />Russell <br />v onlv hiaheat arsae eomoleteLl <br />I COUflge ll m 5+� <br />I <br />� <br />iDLE LNST <br />Cox <br />!V OR TOWN, STATE�Rh O � <br />nZSB <br />.d Island, Ne. <br />G7Y OR T6WN STATE <br />.nd. Nebraska <br />iR TOMlN. STAT� aP16 H HO 1 <br />I ��ervel Celtr98n mrsei arw aeeDl <br />� �3� <br />� a, - <br />� <br />I I�arval bel� OreOI ertA GBetll <br />� 13 � <br />� <br />I I�arval bBltireen a�sel antl tlBatll <br />i L �A� <br />2S, WA$ CAS REFERRED TO MEOICAL <br />i pr NoJ FXAM�NER OR CO NER7 <br />G h ,ESpecdy ves o. 'G <br />Part il 27a OATE OF DEATH (M0. �Y• Y/) 28a. DATE SIGNm (M4 Day. Yr.l zen. neee oF oearri <br />........................ , g� � / ' ' L � g <br />27d DATE SIflNED /b1a. 08y. Yr.l 27a TNE OF DEA^ �� �� 28e. PRONOUNCm DEAD (MO. Oay, Yc1 28tl. PRONOUNCm DEAD (Hm�rl <br />...................... ��� �x M� c9� � y` X 1135 ��^ � � <br />........................ � <br />_ � 27d To Ne beat d my . tleaN xwned et tlre tlma Caffi a�q aM due to Ne ��� 78e. On tlre basis d azamineDOn aeMlor imreatlgahcn. in my o�rdon Ceath axurted at <br />o � <br />.. .......... ............ � �" _ c�el �. � . � a the ti�0, dam aiw p18Ce anE Oue m the cauae181 smteu <br />X eM Title ► ature arW THIe <br />... ..... .............•.. 28a 0�0 T08ACCA USE CONTHIBUTE TO TNE DFI�THY 30a. HAS OROAN OR TI39UE DONA'f�ON BEEN CONSIDERED4 30b. WAS CONSENT 6RANTEO? <br />....•..•...........•••.. X ❑ YES NO ❑ UNKNOWN ❑ YES N6 ❑ YES O <br />TMV ... .......... ..- ... 3/. NANE AND A�DRESS OF ERTIFlER (Pl1YSICAN. COROItlER'S PHYSlCAN OR COUNTV ATTORNEM) lr�e or PNM7 <br />Census Tract No. J�( 7al� � ll � �'� 2�{ �! B ��GE 1/ �o /l�ti� / s c.g.�7 �/�� � <br />. ... .. ...... ....... . .... aze. aEC�s�aaa �. onre �n ev �aisTaaR u�c.. �er. r.� <br />Rev. 3i8g <br />