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Wf/fJV THIS COPY CARR/ES THE 1�i9lSED SEAL OF THENEBRASKA STATE DEP� �-I��ALTM. <br />/T CER7/flES THEBELOW TO BEA TRUE COPY Of,AN OR/G/NAL RECORD OIIFI�L�WITH-�H�S�dTE - <br />D�ARTMENT OF HEALTK, Bt/REAI/ OF V/TAL STAT/ST/CS, WH/CH /S THE_tfGtAL DFPOSiT�RY�� . <br />V/TAL RECOROS. _ <br />DATE OF /SSUANCE - ��'�� - �_ . , , <br />FEB � 1996 �0�20856� as�T,��'��� � <br />tuucouv, NEeaasira n►ESaas�ra <br />9TATE OF NEBRASKA - DEPARTNENT OF HF.�t�tf�:-' -'�_ -= <br />BURBAU OF VITAL STATISTICS - ` <br />CERTIFICATE OF DEATH <br />1. DECEDENT . NAME � � FIF�ST � � . NUDDLE LAST 2. SO( � 3 DATE OF DEATN /MaW/ Oay Y�rl <br />e Januar 19 1996 <br />_ 4. CRY AND STATE OF &pTN /nn� h U.SA. neme cpmtryJ - 5a. AC9E - la� B'utlday UNDER 1 YEAR. UNpER 1 DAY & DATE OF BlRTIi /Alprtfi. Day. Year) <br />n�ai se wos onvs sc. r+oua.s � w�.s <br />Burveil. Nebraska 77 � November 2, 1918 <br />- i. soc�u sECUam n�ue�a _ __ ea au�ce oF oenn+ <br />= 508-05-0663 "° � '"�' °r�' � "`" <br />_ 8b. FACIIIIY • Name /Bnot rnst�. gWe ane�B1 end numbe�l � � ER O��l � ReSWeMe <br />� St. Francis Medical C enter � °OA � ° t�'' S0 p""` <br />& CRV TOWN OR LOCATION OF DEATH Htl MSIDE CRY LIMITS 8e COUNTV OF DEATH <br />G and Island "� 0 N0 ❑ Hall Count <br />9a. RESIDENCE - STATE � COUNTY � 9c. CRV. TOWN OR LOGATION 90 STREET AND NUMBEA IMn�G+ngZry Cade/ 9e INSIQE CRY lIM1TS <br />Nebraska Hall Grand Island 1805 S. Curtis, 688Q3 Y� 0"� ❑ <br />10 RACE • le.g. Wkte. Black. American Intl�an. 11. ANCESTRV le g_ ttaifml Mex�wn. (3mman, etcl �2 � MApRIEp ❑ WIpOWED �3 NHME OF SPOUSE In wne. grve maioen namel � <br />e1C.II5oetJyl � (S��'� . NEVER DNORCED <br />White__ American Mq Ve1ma Reed <br />14a. USUALOCCUPA770N lGrvelmdalwrnFCmeWmmlmus! taE KINDOFBUgNESSINDUSTRY 15 EDUCATION ISOearyomyh�gnestgreEecompletetl� <br />- ��"^9�`�e.�^��c�� Wholesale ElementaryaSecmaaN10��21 CoOegen-aas•i <br />� Salesman Plumbin /Heatin 12th Grade <br />' 16. FATHER • NAME FlRST bUDDLE. LAST t7 MOTFIEq FIRST � MIDDIE MAIDEN SURNAME <br />= Vere NMI Shafer (Dec.) Lissie NMI Hampton (Dec.) <br />� 16. V11A5 DECEASED EYER M U.S- ARMED FORCEST � 19a. INFOHMANT • NAME . <br />�Yes. rro. or urdcl III yes. grve war enC tlales d servzea) <br />Yes WWII 1-15-1940 6-24-1945 Velma Shafer <br />79tr. INFOi�AANT MMLING ADORESS � (STREET OR R.F D NO.. CITY OR TOWN. STATE. ZIP) � � <br />1805 S. Curtis, Grand Island, Nebraska 68803 <br />20.�-SIGNA BLICQiSE . ' �21aMETNpp0i01SPOSITION 27b.UATE � 21C.CEMETERYORCREMATORY-NAME <br />���"�, �%�3 �� ❑� Jan. 22, 1996 Westiawn Memorial Pk Cemet. <br />2�. NERAL F�ME' NAME � 27tl. CEMETERY OR CREMATORY LOCATtON GTV OR TOWN STATE � <br />Rleine Funeral Home �`'� � Grand Island, Nebraska <br />22b. FUNEpAL HOME qpDRESS (STREET OH RFA. NO.. CITV OR TONiN. STATE ZIP� <br />3213 W. North Front St., Grand Island, Nebraska 68803 l i <br />�� WMEDUITE G�WSE (ENTER ONI.Y ONE CAUSE PER LINE FOR 1861b1. AND (cll i ��rva1 between m5e1 antl AeaM <br />- ' �a� ,��i� � ro���9�� �,-v,�.�.tcr � /2 s�tS. <br />- D�IE O, ORA$ A CONSE�UENCE OF I Irte�vy pet�en pse� antl tleaM <br />� I <br />_ � I <br />I <br />DUE TO.OR AS A CONSEQUENCE OF' � I Werval between amel an0 tleath <br />_ � <br />��� I <br />I <br />P � T 07HER SfGNIFlCANT CONDRIONS - CmAiuons � to Me OeaN bW not relate0 � �� PART III IF FEMALE WAS THERE A AUTOPS� . WAS CASE REFERRED TO MEDICAL <br />n , PREONANCY IN THE PAST 3 MONTHS� E%AMINER OR CORONER� . <br />/'s�iy(r/Y!•? L�i�"�L�/�/�4 i''O J'1`Lj'� 1� �asel ves nw res no ves nw <br />28a. 29�. DATE OF IWURY (Afo.. Qay. Yi! 2&. FpUROF INNRY 26E. DESCRBE HOW WJURV OCCURRED . � <br />❑ AwAer9 ❑ U^tlete^m^etl � <br />�� Su�cWe � Pmidmg 28e. INJURV AT WORK �1. PLACE QF IMIU� ` At _, farm. slreet tacWry 26g. LOCqTION STREET OR RF.Q NO. CITV OR TOWN 6TATE <br />oa�e wumn& � <br />❑ Hanxme �me�m res ❑ No ❑ <br />DATE pF DEATH /IN0. pgy. Yil � � 2Ba. �ATE S�GNEp '(Mp.. Dgy. Yr.) 28D. TIME OF DEATH <br />_ S� /r � ' � � S� � M <br />= � � OATE SIGNEp lMo.. Dey. Yr 1 c. TIME OF DEATM � k> 2&. PRONOUNCED DEAD /MO. Qey. YiJ 28tl. PRONOUNCED DEAD fHan! <br />� �� 2G�-�'� . S�T � ,� �°' a � M <br />-�� tl To IhB 68s1 Of my aCUnetl 8110 AuB lo Rie °�� 280. � Ihe basie d BnertnnevOn eM�Or' m <br />j e�vesngaoa6 mY apnwn Ueam occmred al <br />- sl s�BLeA. !� //// ii g tlie M�e. tleDS end yace arp Eue tr� ttie ta�6¢!8) s1EE9d. <br />IS�p!eG?e an T�1 _ '` entl TItlB <br />-` OID TOBRCCO USE CONTRIBJTE TO THE DEATH? � - - HAS OR6AN �1 TISSUE DONATbN BEEN CONSIDERED? WAS CONSENT GRAN7ED� <br />❑ VES �bGl P�0 � UNIaOWN . � YES .� yl NO � VES �NO <br />� ` T <br />3t. NAME. AND ADDRESS OF CERTIFlER tPHVSICIAN. CORONER'S PHVSIGAN OR COUNTY ATTORNEYI l7ype a Prvnl <br />� �-�- NO �.tf�Ii( n1-d�' � <br />��G�T� 32D OATE FLLED .114 N 3� 1��6 <br />