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4/12/2012 11:13:57 AM
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E; NEBRASKA (STATE) DEPARTMENT OF HEALTH <br />Div)n)nn of vial Satintim <br />_ I STANDARD CERTIFICATE OF DEATH <br />I IR OF UENSU9s <br />AU AU OF HEC ` <br />v I I Itr N '11i MI N _. _ <br />I II xhO ILAIf(Q�a../ I R VJUALRFhlnhtl LOF IF(.EASED: — <br />? III (uy ur tow Ir ` Lr`t _ 1 1 S 4. _LSIP —:. `In) <br />Y I t.i. I _ ITmitM1 rlt. RURAL) r <br />Ir) Clt> o <br />a. 1 I ti me of hmlll 1 ur Itll .- <br />wNte RURAL) <br />_ <br />11f t lit <br />h t 1 i 11- for tl ) Id) SLrnt N <br />1) I h (7 Y 1 h al I ution -I lfly. loc.11on)'_..._.____ <br />0Mr4f wl the <br />1 W. F ..)al . _ ••/ 3 .._ — le) If ronl¢n n, n I.o I. U S AA.— <br />NLDICAL LERT CATION <br />II .v l I1 N \N 2a. Dnto of di.th. M Ih.....7... <br />mute .... ... _ ........... <br />_.._ <br />I m <br />+ I ,r C ✓ I l n ttrt r t I /l.d u <br />nl�l wlA—d p+`L7 <br />f^"' ✓Ww`�1 th i 1 et w h.- w+.ell . ......__.F <br />1 Al nrc(d __ and that depth cd the d W d hour ,toted .bout. D—tlon <br />.. Girl 1 f hh..I d <br />tell i. Bi. Ih 411, of <br />(Y—) <br />n\ F Yanra M •ntna n. I I h,ln on d 1 ..L3..KL'>4K �'r"*'a`v_ <br />Othrr <br />rnndlllen .. .. <br />PHYSICIAN ' <br />rv� i try i > wiu I a <br />v <br />- M fl �Lht tear W <br />l� <br />._ (f o .. - {.. / -. whleh d<aN <br />c v [! 1 h - -. -. ✓`Ci•.C.11/1.. - _ / I <br />T (�IV Iw.v�.r rvu`tyl .II.•nr u 1 untr>) Ol ,nv ._. _ h Rcd.W <br />Y. ` I .1 T�4 fym_l/. -- in) 22. If 1 I W fill I th f II In — — <br />11 Ir..� .........__.._ <br />u�- <br />n <br />Z %..rc..e ,atll bl n n.r.` 92.., �,.'.)IT l cL r t �l /connx>) (sar.1 <br />� fF Yi+� <br />LrC au Did In) Ir> 1. nt t h . f.rm. 1. InduArW Pia to <br />r:: <br />Il rtr.r [, n) A11 u _.. .. ._ D.W d¢ned [L..G ✓w <br />II <br />ty� <br />
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