|
STATE OF NEBRASKA '�,� i�,i a S� 4�
<br />� �r -> ;. �,
<br />� ` WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMEN�"D�' yFAL7H'�li,V
<br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE �ffI�11PAi' RECORD. ON�
<br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVI��S,��V �L, Rf�G'ORDS� ;, )
<br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR Vl1"AL RECORDS. � "` � ; •' r-, t �' � `� �-? ' • ' d ' '
<br />' ` �.
<br />DATE OF ISSUANCE •
<br />.� . _ �
<br />' , CG�OPER` ' �r ;:'
<br />JuL �l,� ZQ�� �'"A, S�ISTAl1f� 59�A�f'L� 14�E�TSFRAR �.
<br />pE�LIF2TMENT OF•HEALTIflANQ �
<br />LINCOLN, NEBRASKA HUM�UIF�L�1?�IGES,,r''��.•` " � �
<br />�' `' reti: `=`��� �.'1 �
<br />��STA'!'E OF NEBRASKA—DEPA1tTMENT OF HEALTH � �' ' �`� r ••• � • � � � ,"� �
<br />W
<br />� ,� � �Sry �/flR�n � `�'' .
<br />� Bueesu of Vital Statisltcs �= , �' �; ,;
<br />GERTI FICATE OF DEATH. ��' `� 488 9
<br />�
<br />ASED—NM1E �us� Mmou u►sr gex DATE aF DEATH � MONTN, o•r, rew� i
<br />.. ►. Mar t +�t�st Ma � Female �. 1�.
<br />RACC MMITt, NE6lO, AM!\ICaN INDI�N AGE �1�Si YNDl� 1 ftAt UND[� i OAt OAtE OF lIRTN �noi+rN, o�*, ��rITY CF DEATFI
<br />• liC. � d►�CU� � W.*MD�Y 1 T!AlSI atpl. OarS NOYiS rIN. � 1
<br />. ti�7khi.te s . 39 s� � � June 2 1 37 �.. Buffalo
<br />t1iY; TOWTI, OR LOCATI N OF DFATM n+s�w cm �urm IiflSPiTAt OR OTMER �VSYITUTION—NMf t1I NOT �N lliNl�. 61vf Si�![i AMD NWWfR 1
<br />sce:;•• •�a o� Na
<br />•». I� r. Ye$ �� Good Samaritan Hos ital
<br />SYA OF BIRM i n wot w u.s.�., N�rE CITIZEN OP WMAT COUNTRY IMItRR1ED, NEVER MARaEO, SURYIVB�G SPOUSE � n wne, GIY( MA40lN l/�M� �
<br />� counm � WtDOWED, OIVORGED � x[car i
<br />• Nebraska, � USA �o Ma.�2ied n Wa _ Ma�_
<br />Al SECURITr NtDFMEN USUAL OCCUPAt10N io�v[ uNO oe wOU ooN[ cuc�Ha ror Or �D OF 6USINESS OA INDUSTItY
<br />woai�en un, lMlN li �ETI�lp 1
<br />.. �: Os-�.0-b465 ,,. t3omemaker �`�� ,�. Home
<br />I�Sf ENCE—ST.�fE COUNT�f CITY, TOto�l, OR LOCATION �MS+oi �m �+ym STREET ANO NUMbER
<br />� s�eu+r na o� .w �
<br />�a.�Tebrasks. �w Ha11 ia Grand Island �<a Yes ia. 25 0 N. Webb Rd.
<br />FA7/�R—NAhtE nnt Micwe ust MOTMER—MAIDEN NMAE n�st .uoote w�
<br />'� �s. A1 Jordon Pritchett ►s� 81:iene W er
<br />��•WAS DFCEASEO @YER IN U.S. ARMEO fORCES4 INFORINANT—NA/NF—REUiIONSHl►—µ/�a�►�, ppp�6g �smer o� �.r.o. wo, un o� rowN, s�wie, m�
<br />(YN, ee, u�knsv�l (lf ws, yiw wiar end detst ot uniwy , Gran.d lsland Ne. V�7VQ�
<br />.. �Jo n. �T e�a,y► gue�a�.nd 253o N. Webb Rd.,
<br />'�� �• GEATFI WAS UUSED !Y: ENifR OPIIY ONE CAUSE PfR I�NE fOR o, b, AND c � auu �N vu
<br />! ( 1 f 1 (!1 i[rwtw oNaer �rro oi�rM
<br />�a oi�re e�use
<br />�O� .'� l! �.d`�. Y f/' I t�
<br />� A w N NC
<br />W �ICM \IS! O (b) 1
<br />r �� � S►� o, r � �� N� � � ru�c��►,�� � t� ri�
<br />i�tr�u��rf c�ube �e�, oue ro. �� � eohseaueNCe or
<br />st�nMa rwe uNOe�•
<br />�nNO eause �ws► �` �
<br />(cl 1 " �. C <<t ��
<br />�A�T !1 OTNER SI�Ntf1iANT CONGI110NS: G6NDIiiONS tONit �UtING f0 OGTN !Ut NOT REIATED �A�T Ip. 11 FlMAtE. WAS iNERE A A1RO�5� IF YES we�e nNOiNa4 ca+• '
<br />TO CAL9! GtYEN W►ART yo} �REGNANCI IN THE ► T MONiN59 ��t� w et0� HOlRlO In D!T/WI�tiN6 CIYM
<br />O� Dl�TM
<br />r�s a �+o �+, iw. -P�
<br />ACCs NT, SU�tIDE, IW�1lC1DE, �A tNJ � row,N, os•, ru� � MOUR MOW INJUN1r ,(� CCURRED � E►rtn euruu {� iN Uft IN M�� o� r��r ��, tt[r �� �
<br />GHt 1f�1 ETEltlw ED � t�n� 1 ��(��`� ! n]' �SBII�'' I' O 1�� Q CYC�.@
<br />� `� za ' 1` sa M. zw t�r-1��i�S�"t �p t
<br />. INJIkl� AT WQRRK P1ACE 0F IHJt�V •f Nau, eur, s►aer, r�owr, �OCATION i srnir os �.r.o. No., n o� row�+, er�re �
<br />� tsntln ni o� �+o� arKe Woa.ex �snnn� ��LIx'$1 �i��?t?OT] ,LiE'••
<br />� �. �, I{i�hw�v , , � ,
<br />CERTNKATION— ra+tM a� n�� +.a+M o•� re�u +uro wr �w ww/«e� um oN � em/oro wot M! DEAT11 OCCUR!!D wr ew� ►u�ee, aar na
<br />�MVS1t��w: wr �e•� �oor w R oe i«ou�� o.n, �aa, ro aa �esr
<br />i amraoto rwr � T � � � { ,�� a rr e�neau, ow
<br />7h eecnsia nor � }D '� ` � � 71i � � � ti� 71�. ) � , M. to me c�uua� sr•ieo. �
<br />CERT�IGTION—MEDKAL ExAMtNfR OII tOiONER� aw rHe usro o� rnn Mou� a� ot�n� TN! OIC/OfN1 W43 �lON6YNGl0 6lAD �`4
<br />eurx+avww a na �oo� �►ee/w na �NVts�w�rar, iN rr onN�oa, rwr�rn o�r res� Mou� � �
<br />�m IOCCYMlp ON M! DAN /W0 011F Ip IM� CAUSlISI S��MO �� M. �� �- ( � �' 1
<br />1 M.
<br />CERTI IE�—NAM}[�nn w n�Nn SiCiN� otwte oe �nu DATE SIGNED ���. r. •�u�
<br />�� , � '' �N. 2s ` tk.
<br />� —CE4TIilER , } � sra w �.r o � Keai�e ~ lYIS 6
<br />�.r �n
<br />, aEMA4qN, YAl tEJMETElY OR CfEMA�Q�Y— AMf tQGAT1pN tm O� rowN
<br />� lOtCMf �
<br />�,. Burial „� Westla.wn Memoria�l Paxk 1 ��� Grand Islanc3
<br />OATE q � , �� �� npMM, p�r, v[u i fUNERAt NOAIE—NA+NF AND ADDRE55 � saee+ m�.r.o. ap , cm o� rowp, sr��r, sn �
<br />'!Ar ��'1i7..1L14. 197'7 Liv3nFp�tnn.» Snnrinrman�nl�. C�(}� 1.1 TCn�Mti... !'�.........] T_�___� :1'�_�
<br />ZSb. ' `
<br />.�
<br />2 ��� �!(m IIY
<br />C ��.c.,�t.��r i'��-�--P-'" `� = �" •/`�7�`
<br />�l
<br />ST�f�
<br />1JE
<br />
|