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STATE OF NEBRASKA, _
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT 9F HEALTHY AND
<br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL R,ECPR
<br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS,
<br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE C
<br />07 2012 rANL r ooP R y.,
<br />arc sT A , f
<br />,,ASSJSTAM7'Sib
<br />D kMTMEN7' O HEAL7SF1,d~flp
<br />rJ' y,
<br />LINCOLN, NEBRASKA IJ1~fIV Sy~t/I~E
<br />STATE OF N RMASKA•-DEPARTOWIF HEALTH . x )fir a
<br />U OF Vit'AL STATISTICS
<br />CERTIFICATE O DEATH L/ 8 0 0 fl 7 9 3
<br />OECE NT- FIRST AUL LAST
<br />DATE OF fWla., y, rr.)
<br />Shutt NM? Liv ` Aton
<br />MO e
<br />Jaww" i4
<br />3
<br />1980
<br />I"
<br />-
<br />,
<br />.
<br />RACE-(e.g.. White, Bkeck. American
<br />ORIGIN/DESCENT(•.o..ballan.Illexicon, AGE-wouthday, UN 1 YEAt
<br />IINOER 1 r .DATEOFBIRT11(Mo..Day.ra)
<br />S
<br />Indian,
<br />( )
<br />due
<br />German. oft.) (Sp/'iy) (Yrs.) MOS. DAYS
<br />American
<br />30
<br />HOURS; MINS.
<br />18
<br />1929
<br />
<br />ea.
<br />a.
<br />bb.
<br />,
<br />a..
<br />CI AND STATE OF BIRTH ( not in U.S.A.,
<br />CITIZEN Of WHAT COUNTRY
<br />MAttlED. NEVER MARRIED, NAME OF SFOUSE (NwiEe, giro amid n a•erel
<br />Neb~aBkrt
<br />a m• e~
<br />t1:S
<br />A
<br />1
<br />
<br />(Specify)
<br />Mazitae 'E
<br />Co~cne
<br />o ~l~t
<br />i.
<br />.
<br />9.
<br />.
<br />
<br />SOCIA SECURITY NUMBER USUAL OCCUPATI
<br />COUlNffOFDEATH
<br />ON (Giro kind of work done dari" most KIND OF BUSINESS OR INDUSTRY
<br />ofwarking 1'
<br />~e
<br />S08-30-8239
<br />j
<br />if►etised) , s
<br />Auto Re Ib. Hatt
<br />ancc 1
<br />,
<br />12,
<br />13b.
<br />CITY. TOWN OR LOCATION OF DEATH
<br />INSIDE CITY UIMTS HOSPITAL OR OTHER INSTITUTION - Nate (If not in •itbw, 1WHIM-011010-1 "M ODA,
<br />,
<br />(Specify, Yea er No) RIr• r umber) r) 'A"-f"~et (Speo?F)
<br />'
<br />'
<br />1
<br />GkOW 14tand
<br />1
<br />yea
<br />c~
<br />~C
<br />eacan memokiat
<br />.
<br />I4d_
<br />r
<br />IM.
<br />14c.
<br />NCE -STATE
<br />COUNTY
<br />CITY. TOWN OR LOCATION
<br />STREET AND NUAVIER
<br />1NME CITY LIMITS'
<br />18a.Ne6Aa4ka 1
<br />,3b. Haut
<br />Ise. Gagne lAtand
<br />13d. 1324 N. St. Pant Rd-
<br />-FATHER-WUM FIRST MIDDLE
<br />MOTHER- MAI NAME FI
<br />Livi A4# n 1
<br />I MCA Shut E
<br />Fxeeze
<br />) Delta
<br />1LIEV
<br />.
<br />1
<br />.
<br />,7
<br />.
<br />WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />INFORM ANT-NAME-RELATIONSHIP'-MAILING ADDRESS (STREET OR LFJ* siA I
<br />aUP
<br />L
<br />CY4m ea. or onk) I(N n+. give war and dabs at wrvice)
<br />is F e a 119 - L949
<br />A •
<br />. -
<br />117- MU. Maxine Lev n W~. a-1324 N. St. Rci. Gx sd
<br />BU TRIAL. Cremation, Removal
<br />DA Jan, 17
<br />CEMETERY OR CREMATORY-NAME
<br />LOCATION CITY OR TOWN STATE
<br />no. SwttaC
<br />lnb. 1980
<br />zrk. Grand WOW Cemettu
<br />god. Gkmd Lstumd Nd a
<br />-SLGNA LICENSE NO. FUNERAL H(ME-NAME AND ADDRESS (STREET W R.F.o. NO.. CI111 OR TOWN. STATE M
<br />2nd C~tand I•etand AE. 68801
<br />et-Bu tu-GeddeA 1123 W
<br />„
<br />e
<br />To of my knawledoo. death murrad flew. dab a" olote and &a to the on the bads ate lien-Oild~O► wAvoigason. le ely a~a,aa demo occov d or
<br />
<br />and P~ and dw b t!b caW paled.
<br />and I N@) C 41a. (Signalwo and ride) b"
<br />O 1E SIGNED (Mo., Day. Yr.) NMI TM , Yr.) "ME OF 0ZAT"
<br />I
<br />z3l). t to ' 123c. 6 s50 o M flif 8 24b. zk. M
<br />DATE OF DEATH (Me., Day. Yr.) 11 O ~ N O 14CED DEAD PRONOUNCED DEAD (How)
<br />r
<br />Is
<br />14 January 1980 av$
<br />z 2 M
<br />NAME AND OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNE)n (Type er Print)
<br />S. E. Alabkg MD 2 68801
<br />REGISTRAR
<br />L
<br />qw~?~
<br />ErvED BY REGISTRAR (Mo., Day, Yr.)
<br />i7
<br />
<br />gak . 111'1~
<br />CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (c)) IMOrvol berweon gnat owe loath
<br />p
<br />ow
<br />Al
<br />r
<br />l
<br />E TO, OR AS A ONSEO E Interval beraeee asst and death
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval betvntee amet and dewh
<br />(c)1
<br />pAjff ER SIONWKAW C S-Cooditloas contributing to death but not related FART lit. tF fEMAI WAS ERRE A AUTOPSY
<br />RE TO MEDICAL
<br />Olt co ONER
<br />FRKUNANCY IN TH FAST MONiNSt (Specify Y
<br />11
<br />Y
<br />Yet ❑ No TB. 'o
<br />P
<br />ACCIDENT. SUICIDE. HOMICIDE, UNUT., DATE OF INJURY (Mo.. Day, rya HOUR OF INJURY DESCRIBE NOW INJURr OCCURRED
<br />OE fENONIO W"STIOATCH, (Specify) ^ t+,
<br />> Wa'w...'aC
<br />Z - ~D
<br />Si L
<br />1
<br />1
<br />a
<br />30e. wt G . d s
<br />30d.
<br />30e M
<br />30b
<br />IW AT WORE
<br />ISpwcNy YIN or Me)
<br />r
<br />FIAC Of nQUw - As boom, )ann. strso , factory,
<br />oltko baltding, oft ifped(r)
<br />1
<br />WCATION A J S OR R.F.D. No. Cm Oil TOWN SAW.
<br />Glad[
<br />3a
<br />30f.
<br />
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