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STATE OF NEBRASKA 21012 0 8 2 21 <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT-6 F' EALTHAND <br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE=ORIQTNA'kECORD ON„ <br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVI ES;r I~rTTi44- j-gCORDSe . ' <br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. ' • f <br />DATE OF ISSUANCE <br />p •z1r*LEY: C QR,E <br />SEP 19 20i 1 ."~4~S1~STA'NTS~i~TE4EGISfiRAR`' <br />"pkPARTMENT OF HEALTH AND., <br />LINCOLN, NEBRASKA NUMf4N. S'R XTfCES <br />WfAL S!A'11~~lli~A~M0~Y1~!!'l4REi~IJE1l11~IYtANNIR~`Il~lthllt~L~~ " <br />CER DRATH _ 7164 <br />PeATI+ . a4e» 9RV rem - <br />Arnold Eugene Zloake <br />male June 22. 2000 <br />i <br />l <br />A A01wLt3A MeeYyO •Utimod" I TEAR <br />WAM UNM I DAY <br />b DATE OF OMTH s9kr! YeAY - <br />Central City, Nebra4 ' 18! <br />rTFFg March 6 e 1913 <br />as ®cA + - <br />qe <br />q <br />6 V <br />c'9 3 <br />T•NYp18 <br />f <br />ERG OO" <br />w <br />edgewood Cares Center <br />u ❑ Or+. <br />"vT Y + <br />Ad i+ats <br />» OI TH <br />Grand Island <br />Ta ® <br />Hall <br />^STA 6D OOIN/TT !it CI iOMF100LOCADW F8 MMAWNWMA <br />AAMl6p CdOY/ 9b MrSIDECOiTLWRB <br />Nebraska gall rand Island 1916 Sycamore 68802 Yn~] <br />s4 - N@. T0- . Ae"wi rI L10aa n- AAICES T l1p. now, up-M &Aawt m t8 (fit []%VOWW 13 NAW OF $Yt7M M00 9"ift W111 M <br />t <br />l <br />a <br />l <br />somft DTBeite SON* American W+ER WARM Eve Ross <br />ICA USUAtO=wArm awla ars"afx,,y"010a tAe 10lN1 DF 01596ESS lVDNSTRY t5 EDIFGATIOl1 m <br />dF.01rg At fMIAtAlY10] <br />EroBAetrePrT 10.121 tdl,p~ll eae•I <br />shop Forman Su pl Com an 12 <br />- <br />- <br />- <br />t <br />t <br />FORM-NAM pow W ME LAST <br />17 MOT FMRgI wu_- WAIDEM SURIM'"!E <br />Otto Ferdinand Zlomke <br />Anna Helena Eraumiester <br />to M UMMAMP <br />EtF'EFi w t7 S. ARA~O FOFGEST <br />I% MUM- low <br />IrYamcauicl <br />~TA+~i41T0d~StlMIMTlTI <br />Eve Zloake <br />IRS WOURVAM VALMADORESS ISTFISETORRFD WCITYORTOWAI. STATE. <br />916 Sycamore St. Grand island. Nebraska 68801 <br />L <br />r <br />s <br />2/e 1~fl1pDtIFO'TA111 <br />216 OIITE 21t CEMETERY OR CREWAt(iRY NAi~ <br />• <br />®Dsut ®hea<w0 <br />Iffantlaun <br />2t0 CE&ETERY ~1CrTfWtOAr LOCAYKAY dtv aw lOwlt TF <br />1 <br />4 <br />❑c x Draw I <br />Grand Island, Nebraska <br />am F1:edERAI SS ISTREF70R. <br />TDMM. 87ATE, am <br />9" <br />2929 South Locust St. Grand Island, Nebraska <br />n1OU CAME p~ <br />TER@I <br />Ly0K CAuSE PERM FOR raft. MD190 Yasvy Doug" one am d-w - <br />PARi <br />. <br />l <br />it4 <br />001E TO, acyrre'Tiaaeev~ omw sn oeam <br />IN <br />OOE TO.OW A OF Werrel4ei.een orrM and seam <br />k) ' <br />~~~J} StTYd7~119 - Con 14*ft C *w.6 4Mft dwb w eweNaHd PART in W FEM" WAS 4➢FERB A AUTOPSY 2i WAS CASE REFERRFO TO ME=AA.L <br />P <br />fp TX PRESiRARCY IW THE PAST3GONTMS~ fKA'.1,6ER OR COAOFIEM <br />Y II/ <br />( <br />~ <br />tA~gn 10-54l Yft - Yea No Yp Np <br />ab <br />SNIT DATE OF 6 ROW IW aw nt <br />25, I/OUR OF 1MAPY 280. DESCR UE HOW MU IT Oi..LURRED ' <br />0 1 <br />S.Mft Frbov <br />RaftWIPATM AX 161 PIAC EYAIpYt taO tta a~eslam+r <br />88C,! Nc <br />2%LOCATM STREETORRFONO -:TV OR TOWN STATE <br />© HOmta <br />Ye! 0-01 <br />27e DATTE OP DEATH 20 DW Yrl <br />28a DATE SOM IMP On Tr 1 <br />121D TOME OF DEATH <br />S <br />M <br />2TR GATE 6iWED dw Gn Yrl 27t TOA: OF DEATH <br />28c PR(NtWAiCED DEAD rV* Ody. Yrl 2ft FWNGAYLED CEAD iNawl <br />S <br />"616 Ra <br />bt>twal *VC4V edleatloT.OabaM Ol--efWduC tolM W ° <br />e"wa <br />y <br />d8T /peaS~avNmna4va 8•td MT1Ya8R9gOwt elrtq tytnMtlaeP aCG4rwal <br />i/Y 5 <br />ma.dweonOFtaoeeradueto6iataxlsl6gua <br />0 DOD T <br />oa0 Ti!! <br />OBf=CJSE CCOTIMITE TO TK MATFtr a HAS OROAN OR TISSUE DONATMSEE <br />ann®mq T9fo <br />N CON Dt <br />30 DYIASCONSENTORANTED" <br />. <br />~ YES 0 NO ~ UrAZt~tlyFU ~ YES WC ! <br />~j <br />NO El Yf5 <br />1 <br />• <br />Z_ <br />3t ANDA091ESSOFF CEW(wem !PHYSIOIAN• CORONER'SPLAYS~UINORWONTYATTORN <br />EY <br />I <br />ITYA90FMW <br />j <br />O <br />e <br />, <br />-tt <br />Z 114, <br />g:j <br />01$TRA" II32b DATEFfLBD®YREOIBTRAR Mb.Dp n! <br />Q66~ <br />/ <br />7~ <br />,r.. I AIN 2 R xM 7 <br />i <br />