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Rev. 1 i94 STA7E OF NEBRASKA-DEPAltiMENi OF HEAI.7N AND HUMAN SERVICES FINANCE AND SUPPOR'I
<br /> ; QQ� V17'AL STATISTICS
<br /> ' ��r� �t�3161 CERTIFICATE OF DEATH
<br /> t.DECEDENT-NAME FtRST MIDOLE LAST 2 SE% 9.DAiE OF DEATH IMaNn.On�Yw1
<br /> � Oliver Samuel Fackler Male January 19, 1998
<br /> �"� �.qI V ANO$TAtE OF BIRTH /llnaf h US A..nems�ourMyl S�.�GE•L�sl BIMWay UNDER 1 VEAR UNDER 1 OAV E.OATE OF BIRiH �MbNU.MY YNr/
<br /> North Platte, Nebraska ��"' 69 5° MOS °"`'s x HouAS� MINS Jul 8, 1928
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<br /> 7.SOCIAL$ECURTIV NUMBER 8a.PUCE OF DEATN
<br /> . 507 36 9890 HosP�T��: ❑ Inpa6e�M OTHER' � NureingHOme
<br /> Eb cACIL�TY-Nama /NndmsliMion,pieraheelaMnumbs�J � EROulpalieM � ReeMente
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<br /> VAGNHCS ❑ oon ❑ onnb,�so��r�
<br /> Ee.CIiY TOWN OR LOCA710N OP DEATH !d.1NSIDE C�TV UMITS 8e.CWNtV OP DEATH
<br /> Grand Island �� � No � Hall
<br /> 9a RESIDENCE-STAiE 9b.COUNTY 9t_CITY.TOWN OR LOCAiION 9d.STREET ANO NUMBER /Mt�'ng7'p Cadel 9a INSIDE CITY LIMI78
<br /> Nebraska Hall Grand Island 3005 East Hwy 30 68801 ��� ��
<br /> t0.NACE-�e Q.,WIMe.818cN.AmerkM YMi�n. 1 t.ANCESIAY Ie.g..MsNen.Meucan.OMrtw�,Ncl 12.�MARRIED O WIDOWED t�,NAME OF 9PpUSE /Mwip.p/w�Tlbbn nNM)
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<br /> ���s�^�� White ����German/Native Ame • NEVER pIVORCED Doris Mary Corbin
<br /> O l�s.USUALOCCUPATION /G�wkhMdwaMabnsQuri�gmoM tlb.KINDOFBV8INESSINDUSTRV 15.EIX1CA?ION (Sp�edy W�oonqNMAI
<br /> p dwantmgNb.evenMrerveel Ebmsmapy��Se�aMery lo.t41 � CdAOs If-�as•i
<br /> ° Mechanic Owner Gasoline Service Station 8 « '
<br /> Ct8.FAiNER-NAME FIRS? MIODLE IAST 17 MOTNER FlHST MIDDIE MAIDEN$UHNAME
<br /> � - D Earl NMN Fackler ll Clara NMN Ra
<br /> O • 1!.WAS DECEASED EVEA IN U.S.MMED FORCES7 1W.INFORMANT•NAME
<br /> m (Yn.ro.a uYt.l (N Yes.Wve wa and dems d earvkssl
<br /> � Yes 3 5 46 - 6 8 47 WWII Doris Fackler
<br /> � 19D MFORMANT MARINp ADORESS ISTREEi OR P.f D NO..CRV OR TpWN.S1AiE.ZIP1
<br /> u 3005 East Hwy 30 Grand Island, NE 68801
<br /> � 20 E ALMER-SIGNATURE6l ENS N . 21�.MET/ppOFdSPpSITION 21b DATE 91C CEMf.1ERVORCI�EMAIOp� NAME
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<br /> °' ❑eWw ❑�.�•� Jan. 24 1998 Central Ne. Cremation Serv.
<br /> w E 22a EML •NAME 2td.CEMETERY OR CREMATpqV IOCATpN CI1V OR TOWN 87ATE
<br /> 0 �
<br /> v :� L vin ston-Sondermann F.H. ��'°"'""°" �°an"'°" Gibbon Nebraska
<br /> W j� 22b.FUNERAL IpME ADDRESS (STREET OR R.F.D.NO_CITV Oii TOWN.STATE,ZIP�
<br /> � L
<br /> 0 � 601 N. Webb Road, Grand Island, Ne. 68803-4050
<br /> 21 IMMEdATE CAUSE IENiEP ONLY ONE CAUSE PER IINE FOR IaI.lb�.AND�c�� � MM�vat belween m�sl vW dahn
<br /> g ; PAR'aI Cardiopulmonary Arrest � Minutes
<br /> ZLL WE TO.OR AS A CONSEOUENCE OF� i Irhervel bMwesn mee�ard tleeM
<br /> � �biMetastatic Pulmonary Disease � Month
<br /> M WE TO.OA AS A CONSEOUENCE OF� I Imrvnl be�ween onae�end aeaM�
<br /> ��� Cancer colon with secondary in the lung � Trro Years
<br /> OTHER SIGNffICANT CONDITIONS-Cmdlions comribuNng b Me dealh bW nd related PARi III IF fEMALE.WAS iHERE A N AUTOPSV 25.WAS CASE REFERRED TO MEOICAI
<br /> P�R7 P EG ANCV IN THE PAS�3 MON7HS� EXAMINER OR CORONE
<br /> "Pneumonia, Heart Failure, Diabetes Mel ������,i Y� � ,,as No Y�. ,b
<br /> 26a. 28b.DATE OF INJURV /Mo..Day.YcJ 26c.FKK1R OF MUURV 26d.DESCRIBE HOW INJURV OCCURRED
<br /> � AccideM � UM1ete�mmed M
<br /> G SuMMe � VenA+rg 23e INJURV PT WORK ?61.PUe E OF�e�qV%�Iqmp,larm.rreet lacbry 26g.LOCATION SiREET OA R F O.NO. CI7 Y OR TOWN STATE
<br /> ❑ ❑ ❑ Mie 6uldf �/
<br /> /bmitids Inves�galion Ves No
<br /> Y7a OATE Of OEATH /MO Day Yc/ 28a.DATE SIGNED /Ma.DaY��� 2Bb TIME OF DEA?N
<br /> January 19, 1998 =
<br /> � E� d M
<br /> � II7A.DATE S16NED /Mb.OnV ril 27t tIME OF OEATH �� 2!� PRONOUNCEO DEAD /MO.D�y,Yr/ 2Ml.PRONWNCED DEAO pbu�l
<br /> �� January 21, 1998 8: P M � `� M
<br /> • o� 27d 7 o tne beat d my MnowleAge.deNh me.Aa�e snd ►andt106 to IAe °�� 2Be On�he bsele ol e■aminelion snd a Yrveslgalion.fn my opinqn dsslh occuned a
<br /> eeuselsl raled. �, � Ihe fime.AeM and paca snd due b IM tausele�alelsd.
<br /> I � nrs end tina ens an0 tine
<br /> 29 D�D iOBACCO USE CONTR1BUtE i0�HE THi 3p.a HAS ORGAN OH tISSUE DONATION AEEN CONSIDERED7 30.b WAS CONSENT GRANTEOi
<br /> � VE$ � NO � UNKNOWN � VES � NO � VES � NO
<br /> 31.NAME AND ADDRESS OF CERTIFffR IPHYSICIAN,CORONEHB PHYSICWN OR COUNiY AT70RNEY1 /lype a Ponfl
<br /> Aye-Aye Cheah, M.D. 2201 N Broadwell, Grand Island, NE 6II803
<br /> 32a RE61SiiUR 3ffi.DATE FIlEO BV REGIS7RAR �MO.Day.Yt)
<br /> A certain part of Lot Five (5), Voss Subdivision, which is situated in the East Half of the
<br /> Southwest Quarter and the West Half of the Southeast Quarter of Section Eleven (11),
<br /> Township Eleven (11) North, Range Nine (9) West of the Sixth P.M. Hall County, Nebraska,
<br /> more particularly described as follows: Beginning at the Northeast corner of said Lot 5 and
<br /> running thence South along and upon the East line of said Lot 5, a distance of 280 feet, running
<br /> thence West, at an angle of 90° 00' to the right, a distance of 100.00 feet, running thence North
<br /> a distance of 209.5 Feet to a point on the North line of said Lot 5, Voss Subdivision, running
<br /> thence Northeasterly along and upon the North line of said Lot 5, a distance of 230 Feet to the
<br /> point of beginning.
<br /> I hereby ce�ti'� il�is to be a true �:r��� .,���r:.c� c;;,- ��` �he o;�,,;n�( T�iec� }.���,`� '_'::e '`,�-----
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