Document QJnb6EdQJ2BjaX6pkZR2MrNe7

PERMANENT REGISTRATION CERTIFICATE DISTRICT NO. TEMPORARY REGISTERED CERTIFICATE NUMBER STATE Of UJMCH5 MEDICAL EXAMINER'S - CORONER'S CERTIFICATE OF DEATH STATE FA.fc NUMBER Type, or Print in PERMANENT WK SmCwHWi or Funeral Dkwcton Handbook lor INSTRUCTIONS DECEASED DECEASEO-NAME SEX DATE OF DEATH (MONTH. OA 1. Richard T. Bogner 2jnal e 3. Oan. 30, 2000 COUNTYor DEATH 4. Marshal 1 CITY. TOWN, TWP, OR ROAD DISTRICT NUMBER 6a. Lacon A<JE-l>ST HNDFR YFAR UNDFR1 DAY IDATEOFBIRTH (MONTH DAY.YEARI BIRTHDAY (YRSl Sa. 59 U06. 5b. DAW HOURS 1 MM 5c. 1 sd. May 25 , 1 ML HOSPITAL OR OTHER INSTITUTION-MAKE riFHOI W EITHER. GIVE STREET AND NUMBER) FHOSP. on WST. MOICATE D < OPiEMER. RM. WPAT1ENT (SPt 6b.Grandview Bav 21 Melody l.n 6c. BIRTHPLACE (CITY AND STATE on FOREIGN COUNTRY) 7.Henrv. Illinois SOCIALSECURITY NUMBER io. 336-34-1583 MARRIED. NEVER MARRIED, WIDOWED, OtVORCEO (SPEOFY) sa. married USUAL OCCUPATION melectrician NAME OP SURVIVING SPOUSE (MACNNAME.IFWIFE) WASDECEASED E ARMED FORCES) Bb. Joyce E. Edens g-no. KINO OF BUSINESSOR INDUSTRY EDUCATION ISPECIFYONLY HIGHESTGRADECOMPLETED) SnwifryScona>v<dlgr Co*Rf(M<>rS<| iib.vinvl Mfq. 12. RESIDENCE(STREETANDNUMBER) t3a.Grandview Bav ?1 Melody l.n. CITY. TOWN, OR ROAD DISTRICT NO. 13b. Lacon INSIDE CITY (YES4IO) i3c. ves COUNTY i3d,Marshall STATE i3e.IUinois ZIP CODE 136 1 540 RACE (WHITE.BLACK. AMERICAN MOWN.. eHt)I (SPfEECCIIFFYY) 14a. white OF HISPANIC ORK3IN7 (SPECIFYNOOR YES-IFYES.SPEOFYCUBAN.MEXICAN.PUERTO R 14b. {^NO DYES SPECIFY: FATHEB-ASAME FIRST MIODIE LAST MOTHER-MAKE FIRST MIDDLE CAST H.G. RIF . UNK CERTIFIER oisposition is. Frank Bogner is. Gertrude Barnes INFORMANTS NAMERYPEORPRINT) RELATIONSHIP 17a. Joyce E. Bogner i7b.wife i7c.Grandview Bav 21 Melody Ln. Lacon, IL. 1B.PARTL &*rtiJW.H*lw.qrCTtnpfcafeaHTii--Jti^MatOofcl<cFnnie<tfft^.uden*Aei>|AMyHat^'cd.elwmAjre UUwtf&aauaevnfdiln HImmetfeW Cause (FaYai tfsease ot condSnn Hepatic Failure resulting'tmleilh} OUE TO. OR AS ACONSEQUENCE OF OE(mWEotWnOuKnSifNTWii, days CONDmONS, IF ANY WHICH GIVE RISE TO IMMEDIATE CAUSE (a) STATING THEUNDERIYING CAUSE LAST. (b) Angiosarcoma and Cirrhosis of Liver DUETO. OR AS A CONSEQUENCE OF JL Polyvinylchloride Exposure, occupational, chroni month years PART II. OfrSrsIgrilfiCMXcendftfarHeaneributtpeieKMalhftirtngiraaisanpfcitTSundmlwInccimolyfllnPARTI. AUTOPSY (YESW) 19a. ves were njjw ft<WG5 avajla COnEnONOFC4USEOP CEAT> 19b. NATURAL, ACdOENT, HOMICIDE. ATE OF INJURY (MONTH DAY. YEAR) HOUR SUICIDE. UNDETERMINED. (SPECIFY) 20a. Accident &gob. 1960-1970's 20c. M. 20d. pnlyvinylchl orix ex su INJURY ATWORK PLACE OF INJURY (ATHOME.FARM. STREET. LOCATION(CITY. ML. OR TCWN:ORTWP ;ORRDi. oI tST.Ncr, county; state) F FEMALE.WASTYE (VE&NOI FACTORY, OFFICEeuSJXNO.ETC.) (SPECfY) KANCYHPASTim 20e. ves m B.F.Goodrich 2001550 Cnty Rd. 1450N Henry, 61537 20tL YESD 2la. I CERTIFY THAT IN MY OPINION BASED UPON MY INVESTIGATION ANtVOR THE INQUISITION, THIS DEATH OCCURRED ON THE OATE, AT THE PLACE ANO OUE TO THE CAUSE(S) STATED. AND THAT....................................................... THE DECEDENT WAS PRONOUNCED DEAD ON MONTH OAT YEAfl 2ib. January 30. 2000 AT 21c. 11:( CORONER'S-H DATE SIGNED (MONTH.DAY.YEAR) 22a CORONER'S! 23a. BORtAJ. CREMATION. REMOVAL(SPEOFY) 24a. burial FUNERAL HOME David C. Lenz Jr. 22b.Feb. 3. 2000 5 signature DATE SIGNED .(MONNTTH DAY.YEAH) Violette S. Hnilica, M.D. CEMETERYORCfteMArORY-H'MMET LOCATION cityon town 23b state js; 5>. Z DATE (Month, i. 24b.lmmaculat.e Conception 24c. Lacon. Illinois 24d. 4 STREET ANO NUMBER OR RF.0 CITY on KMH I F2U5aN.ERAl.^llTeREnpTzORMS SKe^NmAToURriEal HSo~m\ e L 25b CL foj 823 E. Fifth St. Lacon, IL. 61540 FUNERALomeCTOft'S LUHOGUCENSE NUMBER 22c 034-010539 ____ LOCAL R' 26a. VR302 (Rev. VB9) StGNATUflE Bbvjl*OoiXMlmenlol Public HeaNh-Office olYldRecords OATEH.ED BY LOCAL RaGCSTRAn (MONTH DAY, YE, ^JLvVJO'O-AhAj^uL^s- 3O;j I on ne^s btahoXpo / HEREBY CERTIFY THAT the foregoing Is a true and correct copy of the death record for the decedent named at Item J, and that record was established and filed In my office In accordance with the provisions of the Illinois Vital RccardtA ct. ^jUiXXU^ yZOOP DATE LOc^x AT LAC Illinois OFFICIAL TITLE. MARSHALL COUNTY REGISTRAR. The original record of this death Is permanently filed with the ILLINOIS DEPARTMENT OF PUBLIC HEALTH at Springfield. Cot clerks and local registrars are authorised to make certifications from copies of the. original record. The Illinois statutes provide ths certification of a death record by the Department of Public Health, local registrar or county clerk shall be prtma facte evidence in a i and placet of the facts therein stated, NGC 04335 PERSONNEL INDEX UAHD Warns BORn6r_ Richard P. R, No. 2004 Dependents Name B. D. SalaryHourly Social Sec. No.. ^6/34/1583 rp. 5/25/40 M~. &_____ DepRelation next of kin Next of Kin Address R.R.l - 21 Melody Ln. Residence LaCOn3 IU ________ 6l540 M & D Printing Co., Signature 246-8263 Tel. No. _ NGC 04336 t>epfc ]' Operation ^ Kite - bate n". . -- U.N.F. 5536/6007 Prod. Oper. Heloer Prod. Ctoer. Helper 2.45 11/15/65 2.56 1/10/66 w Prod. Ooer. Heloer 2.64 Prod. Oper. Helper 2.77 2/14/66 3/7/66 G N Prod. Oper. 2nd Clai s 2.85 5/2/66 P ___ Prod. Oner. 2nd nUs s _2.Q 6/P7/66 N !_______________Prod. Ooer. 2n<T clast1s03/1.07/966 Prod. Oper. 1st class 3.29 5/1/67 O P Prod. Oper. 1st clas5? 3.44 10/16/67 0 prnA Oper, 1st class 3.64 10/14/68 G Prn/1 O;. ot" 1 cl- 1 a a a 5 R7 10/13/69 a 3rod. Oper. 1st rlflftft 4.18 10/19/70 c Prod, Ooer. 1st class 4.41 11/15/71 G Prod. Oper. 1st class 4.57 10/18/71 G Prod. Oper. 1st class 4.82 10/16/72 ----- G------- "5537/600 rrod. uoer. 1st: r.lai; s 4.82 -----S/'7H/7-i Dept. ). L Operation Rate | . Date | t o.n. y 5537/60071 Prod/Ooer. 1st class 5.15110/15/73 1 G l Prodl Ooer. 1st class 5:46l 7/1/74 l G 1 Prod. Oper. 1st class 5.891 12/16/741 ____ G__ | Prod. Oper. 1st class 6.47 11/5/76 1 G 1____________________________ 1 1 5528/20041 Maintenance helper 5.76 1 3/2/76 1 j tt n 6.24. ill/15/76 1 T G 1 Mfrint. r Man 2nd class . Tl II IT II ----------------4-----n----------n------- n------- tt- -------------j----- n--------- n n tl-- 1 6.42. ! 12/20/76 ! 1 6.60l 2/14/77 1 6.771 4/11/77 1 6.871 6/2/77 P A A G I Main. Man 2nd class 1 6.99 ! 8/1/77 G L it tl H H 17.08110/31/77 C | tl U 11 11 77.37 110/31/77 ,, G1 1 Main. Man 2nd class __ 1 7.44 1 1/30/78 i. _x._.. Dept. | Operation .j Rate | 'Date ' | G. N. ! 28/20041 Maint. Man 4f2 Maint. Man #1 1 1j------- u IT n 11 mi 11 11 11 " 11-------rm---- | 11 11 ' M . --- n-----------n--------- G-&.17 1 11 "" | 11 'I i' -j-------TT 11 H 1 I Main. Man ifl 18.10101/29/791 18.89108/12/791 18.86 104/30/791 18.80108/07/791 C P c A 19.07 107/02/791 19.32 107/30/791 A C 19.98 110/29/79 1 110.0801/28/80 1 1 lo.11 4/28/Ho i 110.58 8/04/80 | c c c c 1 11.061 11/3/80 ! $.11 i | 5528/20041 Main. Man #1 11 1 .19 111.06] . . ' .20 111.23 1 2/2/81 ' .17 NGC 04337 Dept. Operation Hate Date ~ O.N.P.---- 2B/200^ Maint. Man 2nd. ----- r,------------n------- n c "TT5!r rr 7.70. ob/Qi/78 07/51/78 COLA ___ COTA U MM II ----- n------------ ri------- n----------rr 7-97 8.10 10/30/78 01/29/79 C&a C IMaint* Man 1st. ------n------------ n--------n -----n------------ n--------n cl n ^8756 n-- TBTSid 03/12/79 0V30/79 P c 05/07/79 __ A______ J____ 1 11 11 11 1 11 1 11 1 1 1 l_ 1 i iii Dept. J Operation >>28/^0041 Mflinf Man 1 H I* ------------------faain. Jttan_JLl ------------------ -------------------------------------Main, -Man- #1 iMa i n. Man _ft.l 1 1 1 Tf 11 u 1 rr IV ft 1 M n II 1 H M tl 1 11 - -- - .... | Rate | Date | 11.401 5/4/81 1 n .ssl r n /ri 1 11. 11/2/ftl1 1i 1 b.2.051 2/3/82 1 ii2. i?.i 5/3/82 1 11.5141 6/7/82 1 h 9 19 1 1/3/83 1 112.14 1 1/31/83 | h 9.S9 1 .5/9/8^ i 12.62 I 8/1/83 I 12.88 1 10/31/83 i 1 11 0-2.94 | 1/30/84 1! i <-G. N. Pr* .17 C 1s r 1 *7 n .1 ,, . i 9r n7 r .02C IOC . 12c . 14G .06C \i / 04338