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g~F'7 S. HASrr~[6s 1-{AS-Fi ~ l~l'E'
ADAMS COUNTY NE
FILER
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REGISTER OF D
EEDS
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WHEN THIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SEbZV1CES
SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD 0NJ~ILE~YY#7!i 'a- -- -
THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATiS`T/I:S,S~C€J~iN~~+K1i1CH~;S ~ , ,
--.-
THE LEGAL DEPOSITORY FOR VITAL RECORDS - ~-=
DATE OF ISSUANCE -~ -~+
FEB 2 ~~~~iv ~Y=s: ~o- _ _
1998 ~ ~~
LINCOLN, NEBRASKA ASS~TAN,T FATE ~EGI~TR,~
HEALTH AND Ht~MAN SEI~S _SYST~M
STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES. FHrANCE !CNU-SIJPPORT Y
VITAL STATISTICS ~ --- _
__ CERTIFICATE OF DEATH ,
---; ~-- ^^~~ MIDDLE LAST 2. SEX 3. DATE OF DEATH lMOnIA. Day. Year/
Leland E. Turner
4
C Male January 15, 1998
.
ITY AND STATE OF BIRTH /Ilrrolin USA.. name country/ Sa. AGE -Last Binhday UNDER t YEAR UNDER I DAV
6. DATE OF BIRTH lMOnlh
Oay Year)
Smith Center, Kansas 'Y`~' 64 5b MDS ~ DAYS .
x.H~uas MINE.
7. SOCIAL SECURTIY NUMBER August 24, 1933
Ba. PLACE OF DEATH l
509-32-1047 HOSPITAL: ® Inpatient OTHER. ^ Nursing HOme
Bb. FACILITY-Name Ill not rnslilulion, give street arrd number) ^ ER Outpatient ^ Residence
Good Samaritan Hospital ^ DDA ^
Bc. CITY. TOWN OR LOCATION OF DEATH other/spec,/y, _
'
Bd. IM
SIDE CITY LIMITS ee. COUNTY OF DEATH
-
Kearney Yes ®
No ^ Buffalo
9a. RESIDENCE -STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER
/Including Zp CodeJ 9e. INSIDE CITY LIMITS
Nebra
k
s
a Adams Hastings 847 S. Hastings 68901 Y
^
10. RACE - le.g.. While. Black. American Indlan 71
ANCESTRY
I
i es No
.
etc. lSPecityl T•T4,
t .
le.g..
tal
an, Mexican, German, etcl
ISPec,fyl 12 MARRIED ^ WIDOWED 13. NAME OF SPOUSE (//wAe. give maiden name/
YYll
l
o American
NEVER DIVORCED
M
Marian Mohler
ARRI -
14a. USUAL OCCUPATION /Grse kindol work done during most 14b. KIND OF BUSINESS INDUSTRY
ol km li/ nq br L ~ ~ / ~~ 15. EDUCATION (Speclty only highest grade compleledl
~
~
~
is
l
dn Industrial manufacturer Elemenl®vorSecpndarylB-121 Colleges-A Ors-I
VV,,
16. FATHER -NAME FIRST MIDDLE LAST 17 MOTHER FIRST
MIDDLE MAIDEN SURNAME
Lewis Turner Louettie Flint
IC. NiAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT -NAME ----
(Yes. pr;-qr unk.l III yes. give war arv] dales nl servlcesl
l~lJ
I
Marian Turner
19b INFORMANT MAILING ADDREGS ISTREu f OR R.F.D NO.. CITY OR TOWN. $TATE. ZIP)
847 S. Hastings Hastings NE 68901
20 MER -SIGNATURE & LICENS NO /
7! a. METHOD OF DISPOSITION 21 b. DATE 21 c. CEMETERY OR CREMATORY NAME
~
~
]
~E,a1/ J ~ Banal ^ Removal January 19, 19 8 Sunset Memorial Gardens
Y ~' ~-
~
2 F NER O E-NA F ltd. CEMETERY OR CREMATORY LOCATION -
CITV OR TOWN $TATE
;~ rand-i~ilson Mortuary ^ Cremation ^ Donal,o,
Hastings NE
22b. FUNERAL HOME ADDRESS )STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIPI -
505 N Bellevue Hastings NE 68901
23. IMMEDIATE CAUS IENTER ONLY ONE CAUSE PER LINE FOR lal.lbl. AND Icp t
PART I
t
l
n
erva
between onset and death
cwt ~ ~
lal
~ e)
W
...~
DUE TO, OR AS A CONSFOUENCE OF
~ G~ti
I Inlervpl between onset' rid tlealh
Ibl I
I
__
DUE TO. OR AS A CONSEQUENCE OP ~ ! __
~^ ~~-_ - --- ~ ~--
-
I Interval between onset antl death
Id
~
OTHER SIGNIFICANT CONDITIONS - Cmdllions contributing to the death but not related PART III IF FEMALE. WAS THERE
PART
A 24 AUTOPSY 125. WAS CASE REFERRED TO MEDICAL
II PREGNANCY IN THE PAST 3 MOMTHS? EXAMINER OR CORONER
(Ages t054J Yes No , Yes No Yes No
26a 26b. DATE OF INJURY /MO.. Day. YrJ 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED
Atcidenl ~ Undelermmetl
^ _ M
i
~
Suic
de
Pend,ng
^ 26e. INJURY AT WORK 261. PLACE OF INJURY - At home. larm. sueel. laclory
oNice building, etc. ISpecily/ 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
Homicide Inveskgalipn ^ ~
Yes No
27a. DATE OF DEAITH /Mo.. DayDay. YYJ 26a. DATE SIGNED /Mc. Oay Yr! 2Bb TIME OF DEATH
~
~
27h. DAT
SIGNED
o. Day. Yr/ 27c. TIME OF DEATH E V o M -
26c. PRONOUNCED DEAD lMO Oay Yrl 26tl. PRONOUNCED DEAD /HOUrI
/'1 /~
9 M °2 ~o
gg° ~ - ~_ ~ ~r //V
1
M
- ~ 27d. 7o the best of my knowledge. tlealh occurred at the lime, dale and a and due to the ~ ° ~ 28e. On the basis of examination and~or investi alion, in m o
causelsl staled ` p
9 y Dlnion Oealh occurred al
~
the time. tlale and place antl due to the causelsl staled.
ISi nature antl Tillel - ~
ISi nature and Title) ~
29. DIp TOBACCO USE CONTRIB TO THE DEATH? 30. S ORGAN OR TISSUE DONATION BEEN NSIDERED~ 30.b WAS CONSENT GRANTED?
^ VES ^ NO
UNKNOWN ^ YES NO ^ VES ~ NO
31. NAME AND ADDRESS OF CERTIFIER IPHVSICIAN, CORONER-S PHYSICIAN O COUNTY A7TORNEYI iType or Print) -
E Adeleke Badejo MD-11 W 31-Kearney NE 68847
32a. REGISTRAR
~~ .~..... 32b. DATE FILED BV REGISTRAR /MO.. Day Yr/
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