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...,I MM., i.■.0 %Pr IMO IM /MI 00M M 1/.i.41-.
<br />*WOO St.
<br />R St, Jam`s, Minnesota
<br />tII•.tM .J. YOMAI L.JUMII T
<br />9 U.S.A.
<br />1.1011 RC
<br />14(. MIOl S ACV.
<br />EOrsp«
<br />WIDOWED. ried
<br />to M
<br />M w .M.
<br />1M..0 yr..... Fr - 9Tr. ..O POOR .MM /
<br />, Miriam R. Roche
<br />,
<br />SOCIAL SECUINY Human
<br />• ,, 483 -16 -8766
<br />USUAL OCCUPATION (G:m lied of .e.l doom doom; most - WINDOW
<br />.l ..e.1:.19 Esf1....w .F NN:..d,
<br />„e isor of Inventory
<br />$USINESS OR INDUSTWT
<br />oh Manufacturing
<br />COUNTY Of DEATH
<br />1.e Lancaster
<br />(ITT. TOWN oil LOCATION d DEA TN
<br />,.b . Lincoln
<br />1
<br />INSIDE CITY LIMITS
<br />(Sp..i4, Y., o. No/
<br />,.. yes
<br />HOSPITAL OR OTHER INSTITUTION - Now (N Rot iR ..M... I O T.OSI OR MST I.... 00A.
<br />9i'• I WK. R. 1 1 �"►•^�"•; t !.. w.e.w.... /Soma /,1
<br />1 . Linco General Hospital I ., inpatient
<br />d .
<br />- RESIDENCE - STATE
<br />,IS.. Nebraska
<br />FAH -NAM
<br />• ,4 (dec.) Carl
<br />COUNTY
<br />„ Hall
<br />CITY, TOWN OW LOCATION
<br />13. Grand Island
<br />+ Sul ET AND NUMBER 1 1N510 CIT/ LIMITS
<br />l(Sp«.{, Y. No)
<br />,Sd 840 Phoenix lo. yes
<br />1 —
<br />Ml$l r IASfiH
<br />B. Dokken
<br />MAIDEN NAME E ItSf M1DDlE UISI
<br />1 (liv.) Lillian A. Ledoux
<br />- WAS DECEASED EVER eN U.S. ARMED FORCES?
<br />,. es ~ W W I I L 2
<br />� ,tY 26-42/8-15-43
<br />INFOIMANT - NAME - 1ELAT10NSN1► - MAILING ADDRESS DIME 011 f D NO. CITY 0R T {� V.
<br />,t• Mrs. Miriam Dokken -Wife -840 E. Phoenix -Grand I ? 1' , NE
<br />sumAE. Cr...o.:ew. ,...e.e1 D
<br />Ap ri l 9,
<br />,o.. Burial ipb 1980
<br />CEMETERY W CWEMATORT - NAME 1 LOCATION CITY Of TOWN STATE
<br />20.Westlawn Memorial Park ; mod Grand Islam+, Nebraska
<br />EM•ALAMER- SIGNATUIE t LICENSE NO FUNE4AI NOME - NAME AND ADOWESS 1394ti1 0* I'D NO. 011 01 904.44, 51•1I. 194)
<br />`,, C j_ ii- ( e -r, ,k 'yi9 ,z2 Apfel- Butler - Geddes Funeral Home Grand Island, Nebraska
<br />...M.l ..e..d • . - -\ e 2 w i ■•• w.y... e.d ol..• e..d dw w 4.. .....4.) .M.1
<br />I + . •1.. Mr .► - A..e4d S.e.w ...d ...1. wr. d.h1 .w e .d 6. ....w. , T O...w. be.., .4 .......w.. e.d,................... w w.. ..
<br />DECEDENE -NOME
<br />MU MIDDLE twtf SEW 0*11 04 DEATH (Me . Doi. 1. I
<br />Holver Clement Dokken J Malei, April 7, 1980
<br />RACE -h.9.. Wb.M. Mock A.... '0 GIN/DESCC�ES ho.
<br />_$.. M.AGE-1.6 I.
<br />ice. AGE - d., ii uNDER 1 TEAR` UNDER 1 DAT T DATE Of t41RTN(Me.. V, )
<br />1Re:el..ttJrsp..YF,•F Whi Ge•mea..NK/1 AGE
<br />62 f Moi. DAYS 4400 . *INS
<br />s _1, (6. , Auaust 17, 1917
<br />�. DATE SIGNED (MO. Do,.
<br />v NCI OF 6CATN _ z• !FATE SIGNED (u. Do,. YT
<br />•
<br />JJb April 8, 1980 lo. 10:15 a.m.
<br />M = K 1 J.b
<br />311 1- 6.41E OF DEATH (Me , Oar. T•. . O PRONOUNCEC DEAL
<br />-
<br />(Mo . Da 1. Y r l
<br />April 7, 1980 1sd
<br />NAM( A140 ADDRESS Of CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN 0* COUNTY ATTORNEY) ( i,p. . 9,,m)
<br />„ Lou J.
<br />WEGISTlAR
<br />WHEN THIS COPY CARDS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINi4L RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST= _ $ECTOl% WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />MAY 3 0 1997
<br />LINCOLN, NEBRASKA
<br />, r RECEIVED R► REGiSTRAt (.0 . 001. v.
<br />J60 .
<br />IMMEDIAT E CAUSE
<br />PART
<br />Ii1ledul 1 arr fail urP
<br />Du( O. 011 *SAC SEOUENCE Of
<br />m Hemorrhaaic cerebral vascular _accident -�
<br />DUE TO. Olt AS A CONSEQUENCE Of
<br />201302907
<br />STATE OF NEBRASKA — DEPARMEN
<br />TT Of HEALTH
<br />BUREAU Of VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />iael� M D- - - ?1 ' outh 17th, Lincoln, Ne L 68542
<br />APR 15 'q9,0
<br />(EN ONLY ONE CAUSE 1E1 UNE 101(01. (bl. AND (.))
<br />& ANLE1 S COOPER
<br />ASSISTANT -STATE EGISTRAR
<br />HEALTH AND HUMAN SERS SYSTEM
<br />•
<br />• Suraical removal of benign intracrdnia -1 meningiolra
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