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_= sr�Te a+rmatusx�+- n�nxxn�rr ��w�ati �� smv�s �� surroar 2 012 0 0 61 � "�"��'"'� 30085� : CER'fIFICATE OF DEATH � �. DECEDENT - w1ME FIR87 MDOIE ul9t 2 SE1c 3 DATE OF �OEATN �Mden Nr. r�/I Joaa L. West Female Se tember 17 2001 �. cm +wo sr�re oF a�arr� nrrorn u.s.�. n�r cwrp sa At;E • ua e�maw u�a � rEU+ uanEp � Mr a D�Te a e�arN �war». ar. r«n Blair, Nebraska na � 69 ��' �� Februar 18 1932 7 SOCUIL SECURTI`/ NUMBER BL PLACE OF OEATM . 506-36-7642 " � "�"" °� � "�"°'� Bb FACIUTY lMna�mWrmwtD�sbeeranOmnCwl � Ep� ❑ � 15825 Howard St . ❑ ow � o��s,��.� Son's home ec. cm rawni or+ �ocnrww oF oFnrr� m. �nsroE cm wars ae. cau�TV � o�rH Omaha �� "� ❑ Dou las 98 SIDENCE � STATE 9E. COUNTY Be. CIT'. TOYVN OR LOWTION 9C. STREET ANO NUNBER (Uetudm0 ZW Caael 9e WSIDE CITV LuAITS Nebraska Hall Grand Island 423$ Ver�nt Ave . 6811$ ''°'� "° � �o. aace - �aa. wnm�. �. a� �. i�. nr�cesrar ie.¢ �an. eeeacm. c�mman..�ei +a � waa�e � vnnowEO �a niae� � saouse m.ae. �e ��,e� �� `�� Wh ite ��"� Amer ican NE1° ° " O F� D Jack Wes t 16i USUAL OCCUPATION ua�e �ad �+,� m�s cu� �w ,�a. Ka�w aF �ss a�arsrar ,s. EoucanoN iso�u+r «w ��a+ro� d�orYm9r�ke`andraeretl/ Eb�nmrya9scanaery 10.�21 CoAege'i��aa5•i Sales Auditor De artment Store 1 t& FATNER - NpME FIR$T 1AfppLE LAS7 77 AAOTMER FlRST M1DOlE MNDEN SUFB�IAME � Clarence Wachter Tena Petersen • ,a was o�c�seo e�u a� us. nr� Faec�sz ,ea wwm�r-wu� Irea m. a a+�.l le yee. o�•�er w aatss a aavwal No Jack West 180. WFOiOlAN7 MAWNO ADORESS ISTREET OR R.F.D. NO_ CITY Op 101MN. STATE. ZIPI 4238 Vermont Ave. Grand Island NE 68803 20. EMB0.LAIEq • 9KiNATURE BIICENSE I'p. � 27a METliOD OF O�ITION 21E. DA?E 21a CEMETERY OR CREMATORY � NAME Not Embalmed �e� �� Se t. 19 200 Seafe Hoffmann Cremator aza auN� rw►� - wwE z�a c�rear oA caEMnroar �aca� cm oa raxna SrnrE Ca bell-Aman Funeral Home ��'°' � dmaha Nebraska � 22E. FUNERIIL NOME ADDiiESS ISTREET OR RF.D. NO.. CITY Oii TOWN. STATE. 21P1 . 444 S. 17, Blair, NE 68008 2a ao�Epin7E CausE IENTER 01n.Y W�E SAUSE UNE Wa iaG lol IeU � Eme+va� eeueen a� am meam P,� �,/�,� ;- �(o� �. �,� � ,*-1 �Pv� � � .� � c g� J WE TO. �1 AS A CON5EQU09CF OF� pmrva� beneen vae� and aeam i NI i OUE TO. ai aR A CONSEWENCE OF: i I�erva� ha� a�se! azWl.�Leam i ' Icl � � PARTOTHEP S�iNffICANT C�1�3 � Ca�6BOrn �np b tlie demh b9 n01 refa�eC PART N IF FEMALE WAS TMERE A 20 AUTQPS�' 25. WAS CASE REFERRED TO MEDICAL �{N TME PA$T 3 NONTlIS� E%NM�'IER �i C�NER'� 0 I�geaio ras No rea nw rae No 28a �b. DATE OF 8�llRY ptb. �l: Yr.� 2He. MWR OF PUURY 2B0. DESCi88E �Y11 IWURY RAEO � � ❑ � M ❑ Su�e ❑ Pertlm9 .28e. 1NJURYATNWRIf � 2& e Fa1J�'-.�tM .fmm.5treel.laclo�Y 2� LOCATWN $TREEfOt70.F.D.NO. qTYORTOWN STATE /�Pecal% ❑ �� 9�^ Ye� � NO � 27a DATE � OEATl1 Ab- Dep. Vr.) 28a DATE SIGNED /4b.. UaY Yr.l 28p TINE OF DEATN � g� � ( ( � g��tt M 27b. �A7E SKiNED /MO.. Oay. Yr/ 27e. TUlE OF DFATN �� y 2&. PROI�IOUNCED DEAD iMO.. Day. Yr.I 280. PFmNOUNCED DEAD /Fkw� � � c 8� �`(� " Z 9��0� e � � • 3 27e. To me Dast d my trwteaga aaurrea at me mre. a�e ana a�e �d eue ro tlie 8�� 2Be. On me b� d ezertunanon ana w erv�genon. m mY �n mam «curtm m trweg cal�elsl s�8tl. � . �/ a. Ihe Mie. Ca� aM Wece aM Cue 90 ihe cmmel9l ammeE. 1 eM Titlel ► �: � / � I� anG TiCe 29 �O T0811CC0 USE TO TME�DEATM! .. ` 3Q8 MAS �AN �i TISSUE OONATION BEEN CONSIDERED� 30A WAS CONSENT 6NANTED� ❑ � � t!, P�A� I `,i7_�___ �. " a , ❑ VES 1� ❑ YES � 1� 31. NAME ANO ADDRE3S OF G� TfF1�i (PLiY.SiCIAN. CO R' PHY�ICIAN OR CW NTY ATTORNEVI /7ype a PrtNI P�f/�� ,e �°�� q � �� o ,v�� `�� E�. tir� .o,�� , a�►�� 6 �� �. �, �,- ; � � �� S�P 1 8 2001 � `� . �� N _ �' � � � �. : �° ; ��. . � Thi"s ceigifi� this��weent ko be a true copy ot an original record on file vith Vital Sta�isat�c �uq1a��Coue��lealth Departmeat. dnaha, Nebraska. Certitied copies must have a rai�e�y��ael�in�thg.ar�a�to the lett. Reproduction� o! thia qraen certiticate are �t leqal cqP4�� , 4�.`�'� ' Date b 18 2001 i�eqistrar�