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STATE OF NEBRASKA 201302190
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND
<br /> HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON
<br /> FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS
<br /> OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. �( �
<br /> DATE��OgqF�!IppSSUA�NCE A5�
<br /> STANLEY A ti
<br /> MAR EY 7 2037 ASSISTANT STATE REGISTRAR
<br /> DEPARTMENT OF HEALTH AND
<br /> LINCOLN, NEBRASKA HUMAN SERVICES
<br /> STATE OF IBCCASKA_C(ACTMENT OF HEALTH 7 9 113 2 5
<br /> SUMMA OF VITAL STATISTICS
<br /> CERTIFICATE OF DEATH S.
<br /> 'DECEDENT-MUMS FIRST NOME LAST SEx BATE Of DEATH(MS.,o..,T..)
<br /> 1 Glen Martin Stewart 12 Male �, Octoker 2,1,..1979
<br /> RACE-Nip..Vf61N,RIntk,AHr te* U EISDESCENT(•.g..MWhn,Meale0M.(Nut-Lan WAS, I UNDER 1 riAEI UNDER 1 D.... .r...J.•.WA SRI..,Day.Fr,)
<br /> Tad:ae.elk.)(Sp•.Uy) Once.OTT fSpe.g,) i U I DM./ I MOS. . DAYS I HOURS, MINS
<br /> 1�.. ¢ A e�S 6. rC 166. 6c. T Jana 129 1913
<br /> [Of MIRTH(R aoI is USA. R M Of WHAT CWNIRT MAltl .NEVEd MARRIED. NAME OF;Ouse/ .nre,gnle sesden newel
<br /> .aeakyl WIDOWED,DIVORCED(Sp.cify)
<br /> E. Aurora, Nebraska 19 Mk 1¢Widowed n,
<br /> SOCIAL SECURITY NUMBER USUAL OCLU•AI.DN(Give triad N Rork dace during sled RIND Or BUSINESS OR INDUSTRY COUNTY OF DEATH
<br /> lof.a.a:eg file,..SA if )
<br /> , o6-09-6868 )a. Retired ins. Agent 136. Insurance I.. a.13,
<br /> CITY,TOWN OR LOCATION Of DEATH INSIDE CITY LIMITS HOSPITAL OR OTHER INSTITUTION-Name Of not in either, R HOSE 01 INST.I.dIcate DOA.
<br /> (Spec4EE�'p.or No) gave.lreH and na«bor) IDn'MM.^r/E�, b.Woee+r(Sp«A.l
<br /> 146 Grand Island II..: _Yee 1.42710 Stewart Drive II...
<br /> RESIDENCE-STATE ICOUNTY I Cllr,(OWN OR LOCATION STREET AND NUMBER INSIDE CITY UNITS
<br /> (Specify Tee or No)
<br /> is.Nebraska 4156. Ball II'h. Grand Island Isd. 2716 Stewart Drive 1s. Yes
<br /> rAlNER-NAME Nib MIDDLE LAST I MOTHER-MAI N NAME mat MIDDLE LAS
<br /> 14 Char]as 14 Stewart JE? Florence Fay
<br /> WAS DECEASED EVER IN U.S.ARMED POIKES? I INFORMANT-NAME-RELATIONSHIP-MAILING ADDRESS (STREET OR E F O NO.CILIA rtweta rr)
<br /> IT«.ne,04.ey LIT pu.9,n-r NW dale el w cN • v VwDLFJ�1l
<br /> Is/10 imMrs._Sam Gri mmi ngea-Aaughter-22Q4 S. Blaine, Grand Island:
<br /> BURIAL Cremation.Rommel DATE CEMETERY OR CREMATCNY-NAME LOCATION CITY OR TOWN STATE
<br /> log. Puri&. 204). 10 2o,. Westlawn Memorial Park I20d. end Yaland RE
<br /> R-SIGNATURE d LICENSE NO 1820 FUNERAL HOME-NAME AND ADDRESS (STREET OE LT D.NO.CUT 04 TOWN,STATE ZIP) 68801
<br /> 2) ft . _. 22 Livingston-Sonierm Es.505 W.Koenis. Grand Island,Nee/
<br /> .a.aA eam...d..ne nw.do..end Pier.aid d..N M- On the bad*of.eaaMedoe end/« ay opinle. M«..md
<br /> ra..b) - -r I,i C M.tine,dole and plea and duo le «e al riled /dyes - /�
<br /> E 2:1102•711..N*J i79Sf1 240.IS,9e«am ad MIN 1.• P �(,y . jy�p
<br /> 1 d Day.Tr.) HOUR Of DEATH E. DATE SIGNED(Mo. DoE,Yr.) n Go .H r
<br /> l$ t8
<br /> >4 :2b. 2x. M lee= 246 10/3/79 24c. 6:20 a.M
<br /> I DATE Of DEATH(MP.,Da,,Yr.) `a PRONOUNCED DEAD PRONOUNCEDDEADINemI
<br /> 1 I aV i I(Ma..Day.r./J r�
<br /> NAME AND ADDRESS Of CERTIFIER(PHYSICIAN.COEONER'S PHYSICIAN OR COUNTY ATTORNEY)(Typo Or O()Z!/9 7th. 9:13
<br /> 68801
<br /> 23. Jan Steele, Der. Sheriff, 131 S. Locust,_ _ arann Isi>zY>ra_xe/
<br /> REGIS �/, - DATE LYED Y R GRSTRAR(MO.Ogy,Yr�f—
<br /> 26a.MarM.M� `� 766. '✓ <T
<br /> P. IMMEDIATE CAUSE ENTER ONLY ONE CAUSE PER LINE 501(al.(bL AND(.11 I.I..,1 boo.e.n ansI owl LIANA
<br /> PART
<br /> IN
<br /> right heart failure
<br /> OW fa,OR AS A CONSEQUENCE Of lemma b.Iwe.e.«,cad(NAM
<br /> (61 cgastiger of VI, right lung
<br /> DUE TO,OR AS A CONSEQUENCE Of mewed between mast end Meth
<br /> 61 psicse Q$ '
<br /> e I Maki ZWgI1pNS-CaMNlom cemmtrows to Math IAA nth MAWA PAST III.II NMMF WAS THESE A AUTOPSY
<br /> pec.4 WAS CMEE ENFMED i0 EIFDKAI
<br /> IPREONANCTINNHPASTSMONTHS? (SpeedyT««NW EFMM IRO COST=
<br /> II
<br /> 1 Y Sp Yet Na)
<br /> Teo No ❑ 7R n0 29.. «a ITO- Yes
<br /> MORON,SINGIDE,NOT.CIOE,UAW, DATE Of INJURY(Mo Day,V.I MOUE Of INJURY DOOM IOW INJURY OCCUIEED
<br /> OR MSC IIMSOOAION INseIN
<br /> 30a. SOH SOc M SOS
<br /> .IMJRn Al WOES NACI Of INTUIT-Al Ieae,fora.WAN.bc.ory, LOCATION STREET OR S E D No CITY OS TOWN STATE
<br /> (SE.rdy rae a ON attics buiNrng,.k fip«UM
<br /> TO.. 70f SO2
<br /> i
<br />
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