Laserfiche WebLink
I <br />i <br />—1 .. IT .ATE OF NERRAIRA <br />I•i:I \ICr MF:.�T DMARTMF,NT OI' IIf- - %LTH <br />A'It�1 Ntatl.tln <br />n u:'In .•� 1'_'6 CERTIFICATE OF DF.ATII <br />1'I.Ar I: OI' IWITH 11. RI'.�11 I'. \� 1. •N'M:, a.r..•rd li•N. If In•trlutbe: n.lboro <br />Y� . • 1 \rl' .. - . .T \T I: `. e �,rr'NT7(. _ Leron •0•YIWaYI. <br />T1,'Y H.r. 1. .. T 11 01 TY <br />TIINt 4 .�,.,..... IIIH t, r. .• nm� . e.It. RL'RYLIl <br />.. T.OYN . <br />' F r r . .n.. �. n...r YRl iT If r e Itr.cl,•nl <br />} ♦AMI . ..: t r .I.i r ,lA.,i I <br />�� rtril I .:.:, 1 A'E �Montnl Ir.rl tYwrl <br />I E\TN; r•• <br />` .�tC .. �1. It I: \�i.' H 1111. \ .'ill M I•Itll1 . I• \T!. OY IOHTH 1 I r Ir t dr t •1 Yr If Unyr is N`n� <br />i r ,. 1 .. .. \ Al.I •.'11 IHIlIr ,...IrI _. -- hen anha�,I N.n. Ir.Y• Ruun NI.. <br />t• 1 �I' t. 1 \TI t. AI— F. it 1 11 HIHTH . taunt >I 1.1.te I. l ITi %E.�' OF WHAT <br />H 1'11 .THY I I.Ar't, a far.i.n rvrvntril IYTIZEN O <br />mil__.' • <br />S. <br />r cnu-R NAME t, M�.nu r M.unes NAMe <br />IIe. NAyL Ot' 11l'%HAN[) OR Wlt'E <br />jc e N'An� •. i:AY .F�.O n 1\ il< IN 1 \ Al-11 i�IRr'EN' 16 Rl'IAL 9ECt'RITT 11 INFORMANTS NAME N.t l ..n � : A E ` <br />Add_ Y r <br />NO, <br />i< `. <. rii t I HAnI MMICAL CERTIFICATION t tnd4YJ au <br />'; C FILL, T IY I.t. {I1.\t. III tO OI: \TII• <br />° •TN. aew �' .a. er n..mr.n w el n�r r sla <br />ml "e.h <br />nve TO I01Qn4iwWW, , <br />F Mut hlhn. tlrnl.. Nerhla ndltien.. 11 .n In. <br />� - O. U me the dl•- , t. �� > <br />,`• . ="hurt �a m b. .M .ndr� >In. ruw Iwie1 • •tln. ` �� <br />Il.n hirh ou..d drat ►. 31 TYI Irl •J��r . <br />I1. OT11I:N 41t:NllTt'ANT CONIIITItIN:i <br />�d amen. trthtlnt t• th• ar.th h.l <br />r•I•tea re t!r "Ilw.w .r ro�dltlen r.nOn. Mme►. ' <br />iY t,e. I•A'r!: IF OPERA I.I,. MAJOR !'I1I11s.;N OF OPERATION- .o. AVTOPBY' <br />TWI T <br />E <br />Y. C3 N. <br />':I•. A' :j ;ENT 1SI•r.ifri ':I e. 1'I.A('E Ot' INJI'ItY Ir .11 - '- <br />ilr. IlITY OR TIIN'NI ICOUNTY) ISTATR) <br />f SUO IOE h.,ra, /.rm, /.rrorr. •tnet. oltlrr bloc. eO.1 OI rur.l .n., —11. RURAL) <br />ROnll NW, <br />n III.,I IY...1 Illour) il. INJURY OI'CURREII • 'it ROW III[) INJURY OCCUR' <br />21.1. T'IMI: IM••nthl <br />11' Whik .t Wo1h <br />INJURY Na Whlle . W-k <br />m. <br />f hrr hV rertilY that I attrnded thr dreraaed Jro,n_ 1.3 .� L, to.. 6., .1 (p..., 184 �, that I Wt an W- <br />'the /a• <br />yea ollt'r on 19.x`, and that death occurr d ........ m . I'em the c 8 and on the date stated *how <br />...rlk <br />'yT 1l- SI' ♦TORE �11AJ ._ BIGN21 <br />tlt E. �y/J �/ /A -- P�"'__�/ DAIS BtON=I 21.. H RIAL :li. IlnTOP CBN61'e ORI'RBMATURY� YId LOCATION (Cy, lows, w yp RENATIOY Relaovnl. I , .. . IsInn (.rand <br />nR1 1 Islsnd, N„bramka <br />DATE RM-1, BY ti I'. tl lt O •- ir1XI.. R. _/ RWl flGryAru� � -- ' Sy; vU�78RAL UIRBI. R'8 IOdATURi A <br />•i 1 neefnn � nr�e ..men., r•,.�..��._ <br />I <br />Fees S w ` Deputy �Y <br />J� <br />