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<br /> WNEN TH/S COPY CARR/ES THE RA/SED SEAL OF THE NEBRASKA STATE DEPARTMENT OF HEALTH,
<br /> . /T CERT/f/ES THE BELOW TO BE A TRUE COPY OF AN OR/Q/NAt RECORO_-�IE i%C�W/TH THE33ATE
<br /> DEPARTMENT OF HEALTH,BUREAU Oi V?AL STAT/ST/CS, WH/CH/S Tb(E�A�Dt�@�1F0�'€OR
<br /> V/TAL RECOROS. = _
<br /> DATE OF/SSUANCE 9 9 i,O 6 e1 0 0 =_ - _ . _ _'`_'�"�`_�
<br /> OCT 151996 = -` -3:'°"�'s���
<br /> Ab�l&T�€ST.4TE�Q/.SJ1.�[R
<br /> LpVCOUY.AABBRA3KA ,;11/EH�,11'.�M6�i�R�//f{�/� l�E - ,� ' i �, k
<br /> � ,....� _.�.--•--•--'�+-�-�.-i- -.�--..�.._ ""' _ .��......� .�z�s_.�.:_.: :. .. _ .l�s �:�.�J5�3J � ...�.. ..,...(l ww
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<br /> � 4 � . . � . �Y�t+�, ��r�r���f��q�Tl
<br /> s . ..__ _ . , . . ,, 8TAtE�N�0it�81fA T DEP�XAT - ;;" `,' '�' .:°s'. #'r� ,'��t�
<br /> ' " ' BUREAU OF VITAL STATI�CS" "-' -_.-
<br /> CERTIFICATE OF DEATH
<br /> t.DECEDENT-NAME FIRS7 MIDDLE lAS7 2.SEX 3.DATE OF DEATH I��n.Day.Yea�l
<br /> Henr David Fisher Male Se tember 23, 1996
<br /> 0.CITV AND STATE OF BIRTH IMnof ir U.SA..name cpmhyJ Sa.AGE-Lasl BiM�tlay UNDER 1 VEAR UNDER 7 OAV 6..DATE OF BIRTH l�.Day YearJ
<br /> Elba, Nebraska �vs� 54 50 Mos. o��s x.�w�,AS' MINS AU ust 15, 1942
<br /> 7.SOCIAL SECURTIV NUMBER Ba.FLACE OF DEATH
<br /> • 508-48-1612 �SP�� � �^��� OTHER � Nursirg Hortie
<br /> !h.�A(�IJ�Yi:Nam�� . .. ,pnQ�MlAbM1yiwabsMar/^u"nDN1 -_- � ER Oulpatlsnl �RseiOSnce
<br /> ■ �2�����i�^�a r�' ��+ � DO� � O�n'�&�w ..
<br /> Bc.CITY.TOWN OR IOCATION OF DEATH Bd.INSIDE GTY UMYTS �Be.COUNTV OF DEATM � � ��
<br /> Grand Island ''� �"° ❑ Eiall
<br /> 9a.NESIDENCE-S7ATE 9b.COUNTV 9c.CI7Y.70WN OR LOCA710N 94.STREET AND NUMBER (IncludilN�Zip Codel G SHO J ��NSIDE GTV LIMITS
<br /> Nebraska Hall Grand Island 2707 W. Division St�. ��� ^�❑
<br /> 10.RACE•(s.g,YVhile.&ack.American kMian. n.ANCESTRV le.g..Nalian.Mexican.German,mci 12.�MARRIED ❑WIDOWED 73.NAME OF SPOUSE /H wile.grve mai0en name/
<br /> Me'��SpecAy) (SD�'N� NEVER pIVORCED
<br /> � ite rican Yvonne Wiles
<br /> ('�j YM.USUAL OCCUPATION /Give kind d.wk Oa�e aYuirg most 14D.KIND OF BUSMESS INDUSTRY 15.EDUCATION �Spenly aNy ngliest graAe canpbleA)
<br /> � d rpking kb.e�sn Arelire0l Elemenlary a SetoMarv 10�7 21 ' I t-a or 5�i
<br /> na r Farm 12 �
<br /> � � 18.FATHER-NAME FIRST MIDDLE LAST 17.MOTHEH - FIRST MIDOLE MAIDEN SURNAME
<br /> � Henr Fisher Lillian Wall
<br /> 1� 1B.WAS OECEASED EVER IN U.S.AfU.AED FORCES? 5-3-1966 �a.INFOfiMANT-NAME
<br /> 3 �r.s.no.«urMc.l In yes.gire wx and da�es a asrvicesl
<br /> ° Yes Vietnam War 4-23-1968 Yv e F�. t�er
<br /> 1%.MFOFiMANT MAILMN�ADDiiES3 � ..ISTREET ORitF.O:NO:.GiY�OR fpMl.STAiE �•.•.-. - :. . , .. � .
<br /> 27 7 W. Divis'on St. , Grand Island, Nebraska 68803 ____
<br /> 20.EM ER-SIGN T RE UC SE . /D� 21a.ME7MODOFDt$POSITION 21b.DA7E 21c CEMETERYORCREMA�ORY NAME
<br /> ❑X e���a� ❑���a� Se t. 27; 199 Grand Island Cit Cemetery
<br /> 22a.FUNERAL IiOME-N 2iC.CEMETERY OR CREMATOFV LOCATpN CITV OA TOWN STATE
<br /> �J fel-Butler-Geddes F.H. �°r�"'°°" �'Doi""� Grand Island, Nebraska
<br />\^��, �2D.fUNERAL fiOME ADDRESS (STREET OR R.F.D.NO..CITV OR TpWN,STATE.ZIP�
<br />��V
<br />� 1123 W. Second St. Grand Island Nebraska 68801
<br /> 43. IMMEOIATE CAUSE (EN7ER ONLY ONE CAUSE PER LINE FOft la6(b�.AND(c�� � ��������'
<br /> PART �
<br /> � �a, Coronary arres t '
<br /> �
<br /> � � DUE TO,OR AS A CONSEW ENCE OF�. � MMenal Oenveen onsel aM aeam
<br /> ro� Hypertensive and Coronory Heart Disease ;
<br /> DUE TO.OR AS A CONSEOUENCE OF: � IMerval be�ween aaei antl Aeam
<br /> i
<br /> i
<br /> ��� I
<br /> � � OTHER SIGNIFICANT CONDITIONS-CmAilqns contriDulirg b Ihe Oeafh dA nd relateG PART III IF FEMALE.WAS THERE A 2< AUTOPSY 25.WAS CASE REFERRED TO MEDICAL
<br /> PART PREGNANCV IN THE PAST 3 MONTHS? EXAMINEH OR CORONER�
<br /> II
<br /> �p (Ages10-54) Yes No Ves No Ves No
<br /> p, 28a. 26b.DATE OF INJUFY /Ab..Day.YiJ 26t.HOUR OF INJURY 26d.DESCRIBE HOW INJURY OCCURREO
<br /> N
<br /> � AcciCeM � UnAetermine0 M
<br /> � Suicltle � Pend�rg 26e.1NJURV AT WORK 26f.PIAe E OF,i�eUMRV�N honig.farm.stree�.lacbry 26g.LOCATION STREET OR R.F.D.NO. CITV OR TOWN STA7E
<br /> olfic bu Itl 50ecM)
<br /> � � Flomicide InvestgalWn y�� �.�p�
<br /> � 27a.DA7E OF DEATH /Ma..Oay.YcJ 28a.DATE SIGNED (MO..DaY.✓r� 2Bb.TIME OF DEATH
<br /> �< �c
<br /> �.<' Sept. 9, 1996 6 � 0 0 a M
<br /> `�i, 27D.DATE SIGNED /Ab..Oay.n.l 27c.TIME OF DEATH `Si}'K y 28c.FRONOUNCED DEAD /Ma..Day,Yi./ 280.PRONOUNCED DEAD /Hdxl
<br /> �
<br /> ��� M �W�� 9-23 --96 1 : 30 vM
<br /> � 270.To the besl d my knowledge.death occurretl at t�e time.Oate and place an0 Aue Io the ��° 2Ba.O�the bssis d esamina� �a investiga� in my Eea occwred at '
<br /> causelsl sa�ed. a the dme.dab an0 place b tha ea s� �/� a
<br /> � -nature and Tide► -nadne aM Title
<br /> r/r�%
<br /> 29.DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS OfiGAN OR TISSUE DONATION BEEN CONSIDERED? .E WAS C NT GRANTED? '
<br /> � V�S � NO � UNKNOWN � VES � NO � �ES a NO
<br /> 31.NAME ANO ADOIr4$OF CEATIFIER(PHYSICVW,COFiONEH'S PHVSICIAN OH CWNTY ATTORNEVI /Typp�fMiny � .
<br /> Robert J . Cashoili , Deputy County Attorney
<br /> 32a.REGISTHAA � 32b.DATE F�.ED 8Y REGtSTRAR /Afa.O�y Yr./
<br /> _ � . _a AAT � � �MA
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