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DEATH CERTIFICATE OF LIFE TENANT
<br /> RE: South Half of the Northwest Quarter (S}NW�� Section Fourteen (14) , Township Nine
<br /> Nine (9) North, Range Ten (10) , West of the 6th P.M. ;
<br /> Northeast Quarter (NE�) , Section Fifteen (15) , Township Nine (9) North, Range
<br /> Ten (10) , West of the 6th P,M. ;
<br /> Southeast Quarter (SE�) , Section Fifteen (15) , Township Nine (9) North, Range
<br /> Ten (10) , West of the 6th P.M. ; and
<br /> Northwest Quarter (NW�) , Section Twenty-five (25) , Township Nine (9) North,
<br /> Range Ten (10) , West of the 6th P.M. , all in Hall County, Nebraska.
<br /> WF�N 7H13 COPYCAf�tES Tlf RA/3ED S�AL OF THE NEBRASKA HEALTI� --_ --_ 3 '
<br /> S1�STENR IT CERT�ES TFE BELOW TO BE A TRUE COPY OF THE ORIOqI�$�•
<br /> THE NEBRASKA HEALTH AND HUMAN SERVICES 3YSTEl1�I,VITAL STi�S�f6�1�� /,S �
<br /> THE LEOAL DEPOSITORy FOR VITAL RECORD� . �=- - ���l�
<br /> _ � ?���a - - ,
<br /> DATE OF/33UANCE r; �•�=''=_��_"_: ,
<br /> -.: -_; - _.. _ __ __ --
<br /> OCT 2 41997 �-_ '4""`���
<br /> as.�sr�rerr-�r�ar��e�sr,�R .
<br /> UNCOLN,NEBRASKA HEALTH AND 1�JM�llf SE�S�
<br /> 4 - = �=:��:f��89
<br /> STATE OF NEBRASKA-D - '
<br /> EPARTMENT OF H�'�€t�F4-_=_-��=
<br /> BUREAU OF VITAL STATISTICS '-
<br /> CERTIFICATE OF DEATH
<br /> 1.DECEDENT-NAME FIRST MIDDLE UST 2.SEX 3.DATE OF DEATH /MOMh.Day.YearJ
<br /> Martha C. Toben Female October 07,1997
<br /> t.CITV AND STATE OF BIFTH /prplir US.A..nems p�unyy/ $a.AGE-Last&rthdey UNOER 1 VEAR UNDER 1 DAV 6.DATE OF BIRTH /MpMlt pgy,ygai�
<br /> Doni han NE �`'�� 91 �.Mos o,��s �.Ho�,RS� MINS.
<br /> August 18, 1906
<br /> 7.$OCIAI SECURTIY NUMBER 8a.PUCE OF DEATH
<br /> • .. a�VJ'tl���M 7 � � 110SPITAL: � InWti��1 OTMEF: � Nursrtg Home
<br /> '�� I�nafr4l�AaqDiMrIflMMdnunMNi . � ER'qp�M � Rssitllnce
<br /> . Tiffany S uare Care Center ❑ oo� ❑ o�„s,,�.,,.,
<br /> &.CI7V.TOWN OR LOCA710N OF DEATH 8tl.INSIDE CITY LIMITS Be.�COUNTY OF DEATH �
<br /> Grand Island �� � No � Hal�
<br /> 9a.RESIDENCE-STATE 9b.COUNTV 9c.CITY.TOWN Ofi LOCATION 9d.STqEET AND NUMBER //neqrCingZp Cotle/ 9e.INSIDE CITV LIMITS
<br /> n I n 3119 W.Faidle Ave. 68801 Y�� N�❑
<br /> 10.RACE-N.y,N�e.Black.Am�ritan kyian. 11.ANCESTRV le.g..IWi�n.Mexitan.ONmMi.e1Cl t2.❑1MRRIED ["1 WIDOWED 13.NAME OF SPOUSE IM w/e.giw maiabn nams/
<br /> �.IlSpecnyl Isosc�yl � ULJ
<br /> NEVER DIVORCED
<br /> 11a.USUAL OCCUPATION /Give kinOd wiprk dms Ou�ng mwi �,� 1�b.KIND OF BUSiNESS INOUSTRY ^� 15.EDUCATION (Spsciy onty nphen grade canpeno)
<br /> d»orkiny xM.sv.n aronrod/
<br /> v �I EMmemaryaSSCOrMaryl0a21 � Cdbgil�a�c5•I
<br /> 1E-FATMER-NAME Flqg7 �u � "
<br /> MIDOLE UST 17.MOTHER FIqST MIDDLE MAIDEN SUfiNAME
<br /> ' r
<br /> C6arles Porth Christina Thaden
<br /> 18.WAS OECEASED EVER IN U.S.ARMED FORCES? 19a.INFORMANT-NAME
<br /> (ves.rw.a unk.l IM Yss.give wer W dares d svvicea�
<br /> 19p.INFORMANT MAILING ADDRESS �STREET OR R.P.D.NO.,CRV Ofi TOWN.STATE.21P)
<br /> P0.E LMER•SIGNATURE 6 LICE E NO. 21 a.METHOD OF DISPoSITION 21b.DATE 21c.CEMETEHV OR CREMATORV�NAME
<br /> '✓�' lL..i �Burial �Removal "� Ql
<br /> 22a.FUNERAL HOME-NAME 21d.CEMETERV OR CREMA70RV LOCATION CITV OR TOWN STA7E
<br /> Livin ston-Butler-Volland�neral Home �°in""°" �°ona�' Doni han Nebraska
<br /> 22b.FUNERAL HOME ADDRESS �STREET pq q.F.D.NO..qTV OF TOWN.STATE,ZIP� �
<br /> 23. IMME�CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR IaI.(D�.AND(cp I IMerval belwaen pns¢1 antl AeaM
<br /> PART '
<br /> � ' I �
<br /> lal G[. '
<br /> � OUE O,OR AS A CON$EpUEM(�pF;
<br /> � Inbrval DMwssn aM Aeatn
<br /> �e i �� �� �� _ •��1 �
<br /> 2`� �
<br /> DUE NSEOUENCE OF:
<br /> � imsrvai oetvresn oneet ana aeam
<br /> lel �Lli • i
<br /> i
<br /> O ER SIGNIFICANT CpNqTiq1$.Cpb�itiona b IM OsaM yu nq�ol� PqRT III IF FEMALE.WAS TMERE A 26.AUTOPSY I 25.WAS CASE REFERRED TO MEDICAL
<br /> PART •
<br /> II �n A � PREGNANCV IN iNE PqST 3 MONTN3. EXAMINER OR CpqpNEq�
<br /> vJ
<br /> (Ages 10-54) Ves No Ves No Vss No
<br /> �. 26b.DATE OF INJURY /Ab..pay.Yr./ 28c.HpUR OF IWURV 26C.pESCR18E NOW INJURV � C RRED
<br /> � Accidam � UMetermined
<br /> M
<br /> ❑ S�� ❑ Pe�M'�9 26e.INJURV AT WORK 281.PLAe E OF I�N.JeUkpy��1t�qmg�arm,sireet.facbry 26g,LOCATIpN STiiEET OH R.F.D.NO. CITY OR TOWN STATE
<br /> ❑ NortwNtle InveatgWqn dFC biib� 50�Aj1
<br /> Ves� Np�
<br /> 27a.DATE OF DEATH /MO,,p�y.yc� � 2Ba.DATE SICNEO /MO..Dey.YcJ 28p.TIME OF DEATM
<br /> �s October 7, 1997 yyy�!!
<br /> ��'�1 27b.DATE SIONED /Mb..Qsy.».J 27e.TIME OF DEATH a��T 28c.pRONOUNCED DEAD /MO..D�y,Yi) 2BA.PqpNOUNCEO DEAD /HOUr� M
<br /> �� October 9, 97 12:35 PM M �s`�
<br /> �� z�e.ro ms ws�a $ � M_
<br /> ^�r eurr.a at n,a� eeb uw place and a,e a me s�c� 2ee.on me wsie a aamiraGon anoi«inveedgaeon,in mr oa�wn aeam occuneo at
<br /> cawNsl shroA. c> � uia tlme.dab and p+cs snC due ro tlw uuaelsl stated.
<br /> � adw and TMN � . aM Titls
<br /> 29.q0 TOBACCO USE CONT E THE DEATH7 30.a HAS ORGAN OR TISSUE DONATION EEN CONSIDERED? 30.b WAS CONSENT GRAN7ED?
<br /> � VES � UNKNOWN � VES NO � � VES .,NQ
<br /> 31.�IAEAplo6n�agonec�'J1�y OVV Li1�/�a�1�(il�$I1�1$I��PIeD a$ a �
<br /> L ,1
<br /> 32a.REGISTRAR �
<br /> � 32b.DATE FILED BV REGIS7RAR (Mb.,qay.Yr./
<br /> 2
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