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� .. WHEN THS COPY CA/�3 T►f RA/SED 3EAL OF THE NEBRASKA HEALTH ANI3HIAMAAl,��ES SYSTEIY�IT CERT�ES 1}E BELOW TO BE A TRUE COPY OF THE ORKilAU1L RLrCt�RD ON i�1�;E'MqT'H THE NEBRASIUI HEALTH AND HUMAN SERVICES SYSTEM,VITAL STATISTIC$.4FCn011��#I IS THE LEQAL DEPOSITORY FOR VITAL RECORD� _- `' _ ��°° DATE OF 133UANCE __ —- --- APR 8 1998 .� �-� A"`a.��R �€S�I�TANT STATE RE+�T�AR UNCOLN,NEBRASKA NEA�TH __ _ _ s�M =.:�= � . -_ _ : 98-�o�4s -_ _=_-=-__ - _ pxsaestvs)xEV.4-sZ STATE OF NEBItASSA — '- . DLPARTMENT O!PUBLIC I�AI.'PH. DSPASTMENT OF HEALTH n sDVCwTiox wxL w�.rwna gnrean ot Vital StatLstics 6 j,� 0 U 6'�.� sixxz�x xo.126Z.?�3 lb _�._ CEATIFICATE OF DEATH srw�rns xo_.._................_..........__._. . .... t.►uei o�ourM 2.uw��wcs�ocNec(w�...�.i.o.ew. 1��..arw..,:a.u....w.......:..r.,� �. COUNTY !! �. STATE �.COUNTT �'�- ��o Neb ka O. CITY.TOWN.OR IOCATION l. IENGTM OF STAY IN iD C.CITY.TOWN.OR LOCATION 1 s�ti. Weat C�rand I �nd , �ira�l. �� .: - . ; :_ . I. NAME Oi �� (If�wt is►etpifd,Oirt thKf nddrta) � d. STREET ADORE55 MOS►IYAL OR 7yy W VLA {NSTITUTWN . � t. i5►IACE OF OEATN INS�OE C1TY IIMITSt YEg❑ NO e. 15 RESIOENCE �h51DE C1TY LIMITS� YES f. FARN RESiDENtEi �ES NO D NO 3.NAM[OI fYn! I{/1/Clt Lmf 1. DATE Alo�fA Dq Yte► �ceuuo DBYid P�'8rik11t1 BaThhart o�rM J�. 3 7,9b4 (7'rW a yria!) S.SE% G. COIOR O:!�ACE � �. MARIIIED 1i�NfYER MA!!P.!£^� •. DaTE�OF atRTM . 9.AGE(/n Kar� K uMOE�1 rW YMOCR it IMS. �� `�__� � !ad DNfAI�1) � X.wW D�r Nwn Yiw. iGiL�. w��EO o �.�«� A . 8 1 x6 �. . USUAL(�CU►ATqN(Ci/t kiw/�J�os►t b�t IOD.KINDOF tUSINE55OR INOUSTRY 11. 110.TNrLACE(Sfolt o►Jotti►�toa�hl) �2•ut�p d`ww�t mwrnrr /rH� oJ wti�/h/q ars iJ rstnsO Truck�"�ver � trucking Vall,a�y Co. Neb. U. S. -17�.FATMER�S NAME IIb.MOTNER'S MAIDEN NAME 11. NAME Oi NUS�ANO OII MfifE Crre�vrer I3arnhart Alice Birk e3�s �th Jacobs IS. WAS DECEASED EYER tM U.S.ARME�fO110E5t 16.SOCIAL SECURITY NO. 17. INiORMAN7 . A�� �Y..."'Y"ee•,.."� "'~..��M.�� 508 03 8396 ve7ina F�th Barnhart, ci�rand Ialand, Neb. I8. CAYf[0/OtATM�EtWe►w�l/O�t Ntut yt►liwr JN�(�).{D).C�f(t).�� INTEIIVAL/ETwEfM ONSET ANO DEATM ►A�T 1. OEATN WAS C�USED�1I: IMMEDIATE CAUSE (�) . S .� �d��i.�/�. DI�TO (D) �vAid pare ria� to � aAoot uwr (e). xaisl tAs a�1e.. DtiE TO(c) IrinO e.ux /eat. O ►ART I!.OTMfR SlGWiiC�M7 CONqipNS CONIAIMlTMG TO DfATN!{J�NOi I![U7E0 TO TME tLI1MIM�l JtSEASF COMd?1ON GIVEM�M►MT 1(�) . WAS AUTO►SY ►ERFORME pD7 < YES❑ MO W u �` IOe. ACGIOENT SUICIDE NO�tIC10F ZO6. oESCR��E HOw�MJURY OCCURREO. (Entts eatart oJi�ju►�is Part!a Pn(1I oJ itew!/.) � D � O 1 �`�j � ��w�� d� t+� /11/ �G� ._ . .. . � IOc T�ME ov Hour ,-'.�loasS.,DN.Yrm . ._ - . - �_ . INJUNY O.t�. o d�00 W. � - .. � ZOd. INJUNY OCCURNED 20r.►utE OF iNJURr(s.'.,i�W oAOrt b�t.�, mI•��TY•T�w�•��1bN � •WUNTY STATE WNILE AT � NOT WNILE,:� �°..��p�•/�al.afnd,o�ict GAI..Qt.) : . . � . .. . . WOIIK AT INONK - � � 2L !�thnd�d tM d�cNS�d lrom ,to �nd lut w�r ti��li��on . D��M nd�t m on tb�d�t�sbbd�bor�:�nd to tAa 8�at o/m�te rl�dp.from tM uua��t�t�d. 22�. t/OMIt � � E4ls) - 22D. DRESS __. : " ZZt.DRTE St6NE0 � . : _< ;� ._. . � � . Z3a gym�t.,,-AtwxipN, , p�TE � L7c. NAME OF CEMETEII'I 01l CRE TORY . 23d. LOCA ION(Cl't�,tMV� 0►ton�fl) (Stats) .�_ , B��.SV"'�r' , ` `;�; ; G�d I818ud. ,.y �b� , a� . Ks 21. DATE RECD.sY IIEG�STNAR-. 2S. R ' SIGNATUR � 2�.NAMEOF MONTUARY Y�«:'��`�.�„�r �`' ^�� 'q�.�"S ADDRESS'�"'�^�"'?°*�"'"`"�"4`".�".x�� JAN 8 - 1964 � Livingatoa-Sonde�atin';��.Qratx�:�alsn�'�Neb.��y �/' �/. . � !:l�� ., ,��c�� .: ��`�. �. ,r��. ,.,�'.,,.�-.,.��w»r�� ,�..r.�