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Rev, ti94 STATE UF NEBRASKA—DEPARTMENT OF MEALTH
<br /> BUREAU QF VITAL STATiSTICS ^^_ 1����
<br /> CERTIFICATE OF DEATH �'��'t
<br /> .���
<br /> �.DECEO T•NAME FIaST M�pplE � UST 2 SE% J.DATE OF DEATH /AfonM Da�.Y�
<br /> I.;
<br /> Edgar Amos Powell Male October 29, 1996
<br /> �.CITY ANO STATE OF B�qTM /Mnpn US.A..narn�oounry� SL AGE•lel�BirtlM�y UNOER 1 VEAR UNDER 1 OAY !.OATE OF&RTM /Abn,n.Da�.v�e�
<br /> Colony, Kansas nn.� 67 se.�.�os. � w�s x.„ouAS; �NS. February 09, 1929
<br /> i.SOCIA�SECURTIV NUMBEii Ba PI.ACE OF OEATM
<br /> � 509-26-6315 MQ$pITA�; � Mp�b�nl QTMEF: � Nv�o�q Fbm�
<br /> . OE.PACIUTV.Nam� /Mrol msOM�on.An"�JP�N�nd mrnMrl � Eil puipatl�nl � H��W�nt�
<br /> � Home: 1130 N.Howard Ave ❑ ao� ❑ om.,,s�,y,
<br /> !e CITV TOwN OA lOCA7qN OF DEATM �.IN&OE CITV LIAMTS Es.COUNTY OF OEATII
<br /> Grand Island �.. � ,,, � Hall
<br /> 9a RESIOENCE•STA1E 9b.WUNTY � 9c.CITY.TOVYN OR LOCATION 9A.STREE?ANO NUMBEF (Mt�WuglppCoO�l 9�.INS�DE C�TY UMti3
<br /> iYebraska Hall Grand Island 1130 N.Howard Ave.,68803 �.,� N,❑
<br /> 10.AACE•I�.q..W��.&atw.�N�C�n MdN. 1 t.ANCESTRY N.4.h�lhn.AhnCYL 6MmYL MC) 12�MARFIED ❑WIOOWED t�.NAME OF SPOUSE /N w.b.pv�mlb�n n�m�!
<br /> � d W�IIe1 '�merican N�EA OIVORCEO Betty Brack
<br /> c
<br /> � laa USUALOCCUPATION (G�H�rnOWwwraa»A,wqmuf� 1�0.KINOOFBUS�NESSINWSTRV 15.EWCA?ION �Spscdyonh �9�+���a^aNbl
<br /> fY � a.w.qm...,•.,�rr.a.m ,
<br /> ,� y Owner/Operator Insurance Claim Service E"""��'°'S"°"°'"'o��r ca�.�.���:o,s-,
<br /> O ? 10.fAT11ER•NAME fMSt MIDOIE LAS7 17.MOTHER FIFST MIOOLE MAIOEN SURNAME
<br /> W � : Ernest Amos Powell Lucy Virginia Fultz
<br /> O ll WAS DECEASEO EVER IN U.S.Ai1MED FQRCES7 19a INFORMANT•NAME
<br /> ` m • r.,.�o a�.,k.� �n Y„.�,,.w.,w an..d sw�ea� 10/28/1950—
<br /> a � Yes I{orcan War �°,'09/1953 l3et Powel!
<br /> w � lyp.INFQqMANT M�W1Nfi AOOAESS ISTREET OR N.F.D.NO.CITV Oil TOWN,STATE ZIP) .
<br /> � m 130 . Howard Ave.,�rand Island,lVebraska 68803
<br /> �
<br /> Cr V 20.EMB�L -SIGNATUt+E i UCENSE NO. j L 21a iaETH00 pf pSP09TqN t1b.OAtE 21C.CEME7ERY OR CAEMATOAV�NAME
<br /> � 7
<br /> z E � � �c�i �e,,,�r ❑H.�,,,� 11/O1/1996 Central NE Cremation Service
<br /> W NEfiAL MOM •NAME �tA.CEMETEi1Y OR CAEMATOAY LOCATION C�TY OR TO�NN STATE
<br /> � �
<br /> V � Apfel-Butler-Geddes Funeral Home �G.�, ❑o�� Gibbon,Nebraska
<br /> W j� Y20.FUNERA�MpME ADORE55 �$TPEET OR R.F.D.NO..CITV OR TQWN.$TATE,ZIP�
<br /> � L
<br /> o a 1123 West Second Grand Island,lYebraska,68801-5899
<br /> 2]. IMMEWATE CAUSE IENTEi10NLY ON@ CAUSE°,ER LINE FOR lal.101.ANO(ell � wnervai bsn.s�n onsa a�a�eai•
<br /> �JJ j OART /1 � � '
<br /> � � ` � i
<br /> Q lal \. , (�f��(�-�-5
<br /> Z LL DUE TO,pA AS A CONSEOUENCE OG i Intarvm banv�en onsei ana ceav
<br /> � �e���L�-���D e E�-�P o a �i� ; nnoN ►—�-5
<br /> � DuE T0.OA�S A CONSEOUENCE OF� • �m�rvai o�rra�n o�se�ana oeav
<br /> �
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<br /> VART�TMEA$IGNIFICANT CONqT10N5•ConOi�pnf Co�bEWnq b IM NaM�oul n01 rNatW PANT 111 IF FEMAIE WAS TMEAE A 2� AUiOPSV 25.WAS GpSE aEFERR"cD TO�AED�CAI
<br /> „ PREONANCY IN iNE PAST�MpNTHS� Fj(AMINEA OR COAON'eA'
<br /> IAqsa 10•Sq Yn rro vas No vsa No
<br /> 2!a �E.OATE OF INJURY fMO.Day.».� 2EC.HOUR OF INJURY 2lA.DESCR18E HOW INJURV OCCUHRED
<br /> � AcaO�M � U�ANUmm�d M
<br /> � SmcW� � VenOinq M�.IN,IURY AT WORN 2M P C OF iNJUi1V- ihom�,Ixm,ausN.htuxy 28g.LOCATION STREET OA F.F.D.N0. CItV OF fOWN STaT'e
<br /> o � � �.�.�. ���r
<br /> �+m�Ka. im.my.non va rw
<br /> 27a OATE OF OEATN �Ab.Oq Yr J 28a.DATE SK3NED /MO..Day.vrl 280. iIME Of OEATM
<br /> � b�3 � � V� \ V M
<br /> a �
<br /> �� 27b.OATE SIGNED /Ma.Oay.Yrl 27a TIME Oi��TH 2Ee.PRONpUNCED OEAD lMb..Day.Yr.) 2EQ PRONOUNCED OEAD ;HOwI
<br /> ��� '� - 3a'`� I� J � C� M ��=�
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<br /> ' 27a. to m�W�I d rny �.a oeew. m�wn aaN �vM 0w a pw! � � 2M.On eh b�sia d aam�naoon uq�a nv�seqahon.in my opmqn Oaam xewrsE a�
<br /> m � m an i
<br /> eau�NSi mnd. s ns nm�.em va pua ana aus a nn ewss��l nusa
<br /> S�nanx�anC Tmel► �� n �..�~' M'� � �ars aM ThN
<br /> 29 Oi0 iOB�CCO USE CONTRI iE TO n�E OEATM? J0.a N�S ORO�r10R TISSUE DONATpN BEEN CONSIDERED7 �O.b W�S CONSENT GR�NTED?
<br /> � YES �0 � UNKNOWN � YES �O � YES NO
<br /> � 91.NAME AND ADORESS OF CERTIFIER IPMVSICUN,CORONER'S PMY$ICIAN OR CWNTV ATTORNEV) lTyp q�Pmry
<br /> Dr.John J. Cannella,7291�1 Custer,Grand Island,Nebraska 68803
<br /> 32a NEGISTMF J2p.DATE FI�ED BY REGISTRAR /Ab.,DIy.Yr./
<br /> FOR VITAL STATISTICS USE ONLY
<br /> Place.......................A............._.................B................................C................................D................................E................................Part II......................TMV...........................
<br /> NSC...................................................................................:...............................................................................................................................................................Census Tract No.
<br /> Wor k......................................_..................................................................................................................................................................................................................................................
<br /> UC..........................................................................................................................................................................................................................................................
<br /> Reject..................................................................................................................................................................................................................................................
<br /> �rn,�w.nn wr Nw e��.arei.r o.n..�
<br />
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