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<br />200406283
<br />WHEN TM COPY CARIOUS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN 39PACES
<br />SYSTEPA IT CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ONF/LA
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC"EgTlOiflt _ )S `
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. r3
<br />DATE OF ISSUANCE
<br />JUN 17 2004 ASS647i W SAMAVOISTMR
<br />LINCOLN, NEBRASKA HEALTH AND MAfELW fE-fM_ CES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES _ PQRT
<br />VITAL STATISTICS {"} /� (}
<br />CF.RTTFTCATF OF DEATH - if `t V
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />1 DATE OF DEATH /Month. Day. Year)
<br />Kenneth Ronald Reown
<br />Male I
<br />March 8, 2004
<br />a. CITY AND STATE OF BIRTH /Hnot n U.S.A.. name muntry)
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH [Monts. Day. Year)
<br />MOS. DAYS
<br />Sc. HOURS' MINS,
<br />(YMI 5b.
<br />M
<br />=
<br />June 28, 1924
<br />C=2
<br />338-24-5618
<br />nn1
<br />8b. FACILITY -Name fenot instMAW, giro sheet and number)
<br />=
<br />❑ DOA ❑ Other (SpectWt
<br />Bc. CITY. TOWN OR LOCATION OF DEATH -
<br />8d. INSIDE CITY uMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yes ❑X No ❑
<br />I
<br />Hall
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<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER ftnduding Zip Code)
<br />9e. INSIDE CITY LIMITS
<br />n
<br />Hall
<br />Grand Island
<br />1825 (Wand Island Ave. 68803
<br />Yes © No ❑
<br />10. RACE - (e.g., White. Black. American kdian.
<br />11. ANCESTRY le.g.. Italian. Mexican. Gartman, etc)
<br />� MARRIED ❑ WIDOWED
<br />CL
<br />etc.)(Specify) White
<br />112
<br />(spi American
<br />NEVRER DIVORCED
<br />Wilma Smith
<br />14a. USUAL OCCUPATION /Give kind of work obne during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION
<br />(Specify only highest grade completed)
<br />Elementary or Secondary (0 -12) College 11 -4 or 5 -1
<br />of working life, even d mfireo)
<br />Manager
<br />St. of NE-Dept. of
<br />12
<br />16. FATHER -NAME FIRST MIDDLE LAST 17,
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Clyde Keown
<br />Irma Babcock
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? WWI I
<br />19a INFORMANT -NAME
<br />(Yes. no. or unk) I (If yes. give war and dates of services)
<br />Yes INov. 11, 1944 /Jme 8, 3946
<br />Wilma Reown
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE ZIP)
<br />1825 Grand Island.Ave., Grand Island NE 68803
<br />21 a METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />ruA��O.
<br />/4,)
<br />® Burial ❑ Removal
<br />litumh 12 2004 Westli-on
<br />Memmiza Park Czmetery
<br />a FUNEFIXL HOME -NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />All Faiths Funeral Home
<br />❑Cremabon ❑D0na60n
<br />Grand Island Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />2929 S. Locust St. , Grand Island Nebraska 68801
<br />23. IMMEDIATE CAUSE
<br />PART
<br />�
<br />(ENT IT NLY NE CAUSE PER LINE FOR [al. (0). AND (c)) Interval between onset and death
<br />�
<br />I dal � Y l�
<br />l� C e I
<br />DUE T0, OR AS A CONSEQUENCE OF I Interval between onset and death
<br />I �^
<br />I
<br />(b)
<br />DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and death.
<br />I
<br />Idl I
<br />OTHER SIGNIFICANT CONDITIONS - Cprditions contributing to the cleats but not related PART
<br />III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />N
<br />(Ages
<br />10-541 Yes No D
<br />Yes No
<br />Yes No Fj
<br />26a.
<br />25b. DATE OF INJURY (Ma. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />SCRI BE HOW IN, JRY OCCURRED
<br />CD
<br />N CD
<br />12266d.OE
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />26f. PUi� bi ( F INJURY �SAt homie• farm. street. factory
<br />2fig. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />011f6 /ec�l'1
<br />27a. DATE OF DEATH (MO.. Day. Yr)
<br />co
<br />28a. DATE SIGNED (MO.. Day. Yr.)
<br />281b. TIME OF DEATH
<br />March 8, 2004
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<br />27b. DATE SIGNED (Ma.. Day. Yr.)
<br />27c. TIME OF DEATH
<br />i G
<br />28c. PRONOUNCED DEAD (Mo.. Day, Yr)
<br />28d. PRONOUNCED DEAD /HOUrI
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<br />200406283
<br />WHEN TM COPY CARIOUS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN 39PACES
<br />SYSTEPA IT CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ONF/LA
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC"EgTlOiflt _ )S `
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. r3
<br />DATE OF ISSUANCE
<br />JUN 17 2004 ASS647i W SAMAVOISTMR
<br />LINCOLN, NEBRASKA HEALTH AND MAfELW fE-fM_ CES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES _ PQRT
<br />VITAL STATISTICS {"} /� (}
<br />CF.RTTFTCATF OF DEATH - if `t V
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />1 DATE OF DEATH /Month. Day. Year)
<br />Kenneth Ronald Reown
<br />Male I
<br />March 8, 2004
<br />a. CITY AND STATE OF BIRTH /Hnot n U.S.A.. name muntry)
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH [Monts. Day. Year)
<br />MOS. DAYS
<br />Sc. HOURS' MINS,
<br />(YMI 5b.
<br />North Loup, Nebraska
<br />79
<br />June 28, 1924
<br />7. SOCIAL SECURTIY NUMBER
<br />Be. PLACE OF DEATH
<br />HOSP! AL ❑ Inpatient OTHER: ❑ Nursing Home
<br />338-24-5618
<br />❑ ER Outpatient Residence
<br />8b. FACILITY -Name fenot instMAW, giro sheet and number)
<br />.aM GraLid IslaYd Ave.
<br />❑ DOA ❑ Other (SpectWt
<br />Bc. CITY. TOWN OR LOCATION OF DEATH -
<br />8d. INSIDE CITY uMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yes ❑X No ❑
<br />I
<br />Hall
<br />9a RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER ftnduding Zip Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1825 (Wand Island Ave. 68803
<br />Yes © No ❑
<br />10. RACE - (e.g., White. Black. American kdian.
<br />11. ANCESTRY le.g.. Italian. Mexican. Gartman, etc)
<br />� MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (If wife. give maiden name)
<br />etc.)(Specify) White
<br />112
<br />(spi American
<br />NEVRER DIVORCED
<br />Wilma Smith
<br />14a. USUAL OCCUPATION /Give kind of work obne during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION
<br />(Specify only highest grade completed)
<br />Elementary or Secondary (0 -12) College 11 -4 or 5 -1
<br />of working life, even d mfireo)
<br />Manager
<br />St. of NE-Dept. of
<br />12
<br />16. FATHER -NAME FIRST MIDDLE LAST 17,
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Clyde Keown
<br />Irma Babcock
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? WWI I
<br />19a INFORMANT -NAME
<br />(Yes. no. or unk) I (If yes. give war and dates of services)
<br />Yes INov. 11, 1944 /Jme 8, 3946
<br />Wilma Reown
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE ZIP)
<br />1825 Grand Island.Ave., Grand Island NE 68803
<br />21 a METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />ruA��O.
<br />/4,)
<br />® Burial ❑ Removal
<br />litumh 12 2004 Westli-on
<br />Memmiza Park Czmetery
<br />a FUNEFIXL HOME -NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />All Faiths Funeral Home
<br />❑Cremabon ❑D0na60n
<br />Grand Island Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />2929 S. Locust St. , Grand Island Nebraska 68801
<br />23. IMMEDIATE CAUSE
<br />PART
<br />�
<br />(ENT IT NLY NE CAUSE PER LINE FOR [al. (0). AND (c)) Interval between onset and death
<br />�
<br />I dal � Y l�
<br />l� C e I
<br />DUE T0, OR AS A CONSEQUENCE OF I Interval between onset and death
<br />I �^
<br />I
<br />(b)
<br />DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and death.
<br />I
<br />Idl I
<br />OTHER SIGNIFICANT CONDITIONS - Cprditions contributing to the cleats but not related PART
<br />III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />N
<br />(Ages
<br />10-541 Yes No D
<br />Yes No
<br />Yes No Fj
<br />26a.
<br />25b. DATE OF INJURY (Ma. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />SCRI BE HOW IN, JRY OCCURRED
<br />Accident Undetermined
<br />M
<br />12266d.OE
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />26f. PUi� bi ( F INJURY �SAt homie• farm. street. factory
<br />2fig. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />011f6 /ec�l'1
<br />27a. DATE OF DEATH (MO.. Day. Yr)
<br />28a. DATE SIGNED (MO.. Day. Yr.)
<br />281b. TIME OF DEATH
<br />March 8, 2004
<br />=>
<br />as
<br />>�
<br />M
<br />27b. DATE SIGNED (Ma.. Day. Yr.)
<br />27c. TIME OF DEATH
<br />i G
<br />28c. PRONOUNCED DEAD (Mo.. Day, Yr)
<br />28d. PRONOUNCED DEAD /HOUrI
<br />6°
<br />E3
<br />i6
<br />2:24 M
<br />�FS
<br />¢_�
<br />M
<br />° =
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<br />27d. To the best of my knowledge. death rred at the tuna, date and place and due to Me
<br />° 8 28e. On the basis of examination and nor investigation, in my opinion death occurred at
<br />~
<br />causelsl stated t t
<br />8 o the time, data and place and due to the causels) stated.
<br />ISi nature and Titiel ►�
<br />(Signature and Tide)
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />❑ ❑ NO U<NKNOWN
<br />❑ YES I\ I NO
<br />❑ YES [�NO
<br />YES
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type 0rPdntl
<br />Sitki Co ur M. P., 2116 W. Faidle V Ave. Grand Island Nebraska 68803
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Ma. Day. Yr.)
<br />BAR 2 2 2004
<br />
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