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(dec.) Peter
<br />▪ Respirator failure
<br />DUE T. OR AS A C E a:
<br />200 -
<br />Ot1UEY At waft
<br />tOftabT..
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HMALtH ;4filD
<br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE-ORIG L_RECORD t4N
<br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES,• t.IY Lft(F(RD §,. ; !
<br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. j /, ,.•'''
<br />DATE OF ISSUANCE
<br />FEB 252013
<br />LINCOLN, NEBRASKA
<br />Vir it Christian Petersen
<br />.rle.w ENT (O.O.. INMoo. M.a.crn. • E - WO S md.*
<br />(3...w... me.) (Soot* (Pm)
<br />Danish l� 65
<br />A - • ( .M is U. .A..
<br />E xete r Nebraska
<br />SOCIAL UMW NUMBER USUAL OCCUPATION (cis. 14.41 de Nl t)iw. if..r:w.e.d
<br />12 . 507 20 0409 r Production ' Worker 14
<br />TTY
<br />WHAMMY UNITS
<br />Yoe or No)
<br />TIt. es
<br />•
<br />• 1_
<br />�.T
<br />Tr
<br />KIND Of BUSINESS OR INDUSTRY
<br />0
<br />13b. Wholesa a Food
<br />1
<br />•Ti
<br />, . Ty
<br />.k,t (Sootily)
<br />Ilh
<br />CITY, TOWN OR LOCATION 01 NAM
<br />Grand Island
<br />Rf1IDENCE -STATE COUNNTY
<br />, se Nebraska ,,. Hall
<br />BURIAL Crofton**.
<br />Burial
<br />r)
<br />23b February 12, 1987
<br />el my howeriespo.
<br />iiielbstriO ma) Amon,
<br />.,,. r• T: . ' i i . • . r - -tom 7 y* .
<br />TY,
<br />CI TOWN OR LOCATION
<br />Grand Island
<br />UN
<br />A
<br />8 :05
<br />a
<br />.N
<br />WIDOWED DIYORC
<br />Marne
<br />HOSPITAL OR OTHER INSTITUTION - Nom. (N ..
<br />n.W in MIN
<br />ah 10ed1 al Center
<br />T\ .
<br />P • • NCEO DEAD
<br />(M., Day, Yr.) w..N
<br />bath .T ewiu aaand* r. K Mt
<br />!A ..N........
<br />• . AND. MN* ..d .4e. .t♦ Ie. w N.e ..ewd
<br />Y)
<br />R 1
<br />0(Spai(r)
<br />24.
<br />24.. el, ..I TN..) ►
<br />( yp.
<br />or P,i w)
<br />Hugh . Woods, M.D., VA Medi Center, 2201 N. Broadwell
<br />y.
<br />Or "t.)
<br />February 8 1987
<br />DATE 01 NM (M... Orr. Yr.)
<br />, _Janua 12, 1922
<br />( 2Pre maiden NNW
<br />,Joan Corrine Wickland
<br />t.)
<br />COUNTY Of DEATH
<br />Hall
<br />STREET AND NUMMI
<br />, Sd _ Rt . 3, Box 62F
<br />Y
<br />F :1
<br />K sop Olt INST. talks. DOA.
<br />Oe1rNt.ft(low. let .N
<br />. NMe.t MANNA)
<br />,,b In • at i ent
<br />2a. Grand Island Nebraska
<br />24b. Mow) N
<br />PRONOUNCED DEAD Mow)
<br />Grand Island, NE 68803
<br />(NA... r. Yr.)
<br />» ,Metastatic melanoma brain, lung and liver
<br />Out tO, OR AS A CONSECHANCE 01:
<br />„,Mali ng antt melanoma, right shoulder
<br />ma , OwIR S ONSM0 $- f «IM«. .,.A.n.R » ■..d. Iwo e.. r.1.p/
<br />▪ Obesity, severe
<br />ACGBbe4, WAtAE. 00•101114. 00•101114. welt , OATt Co s Haw. w. Oq, ••
<br />Or POONA owOOH ATiQN (5....Nf)
<br />PUt1 Of - r tw... ewe.
<br />NM* bw1.O. wt (1
<br />2M.
<br />STATE Of NEMASIIA- OEPARTMENT Of HEALTH
<br />SUOMI Of VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />STATE OF NEBRASKA
<br />201302083
<br />HI
<br />(E
<br />«•vE w
<br />0. lwn
<br />N
<br />Tit/CAMP.
<br />H -MAI
<br />2ot.Westlawn Memorial Park
<br />1.1, (`1. AOAO* fen
<br />M. N IiMINl. P** THEN
<br />W ►µf f
<br />30d
<br />ST'ANLEY'S{JC°OPER
<br />'ASSISTANT STATE REGISTRAR
<br />t JJ',4 T i,, OF. HEALTH AND
<br />.HUPI,AN. SEPVI ±E5
<br />Petersen 17, (1iv . ) Helene Christensen
<br />WAS DECEASED EVER IN U.S. AIMED EOICES1 INPORMANT- NAME - RELATIONSHIP MAILING ADDRESS 411111, Olt t...O. NO.. CITY On TONStrol i*)
<br />tot..... « .*b. f710 -16 -427 w.y. 08 0 V 1
<br />,,. Yes —21 -45 ,,Joan Petersen, Wife, Rt. 3 Box 62F Grand Island, NE
<br />CEMETERY OR CREMATORY - NAME LOCATION CITY OR TOWN STATE
<br />-NAME ANO AOORESS ($T1EEt Or 4f.O. NO., VT? 04 TOWN. $fait LN)
<br />fel-Butler-Geddes 1123 W. 2nd Grand Island, NE. 68801
<br />A"!r W
<br />ISi.ti1, Yw it Ni) K0 4M
<br />Y.. t N. 0 2 No
<br />mows Y RY 000YM1O
<br />SHEET OEEJO.N.
<br />87 02066
<br />24d
<br />INSIDE CITY LIMITS
<br />(Spot* Yu er N.)
<br />)s.. 110
<br />Weft stowed ot
<br />AH.na1 NINON. NNW and d..
<br />2 Hours
<br />a..w..1 A...a.. Nod dot*
<br />4 Months
<br />I.1.oW Know ea.w and d."M.
<br />2 Years
<br />(SE.t*wr.. NN
<br />Cm OR 1011/N STATE
<br />
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