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6/20/2013 11:56:01 AM
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011-449
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PHS- 794 c(VB11 REV. {-U <br />FEDERAL RtCURTrT AGENC! BTO O! N£9 6w <br />PuRLIy NEALTS RERVICE DEPARTMENT MPrALTH r <br />Burs" *Vlm gb s.tim J 1- 7926 <br />19IRTS VA 12A__ CEItTIFICAT$ AT <br />x -- <br />i COUNT! ,.?•iJ1 �tr. <br />. STATS Nebr � DNTZ Hell � <br />/y! p ®� r��{ •RmSr, �ri4 R..)) a L E N 0 S O a Crr!• (u COW& r RUR&W <br />0W9rN• "! 83'AT it Dlw) o } <br />snd TOWN Grand Island <br />r. .� <br />HOSPITAL A 10 E } -vltr r l.wtuuoi d•e .tr..t .Bar. A STARRY (Y ev A e. 1-a <br />r I.r+U11 ADDHE <br />eat Fr t S� Se 1507 Kest Front Street <br />tAR {, DAIS (Ymtw ( . <br />r r 1 Lan •an DE&TS 8 1 19b1 <br />El PARRIED 4 DATE Ot RIRTN {. A- (1 b�rraa Y U I 1 Tr. Y U H Sri <br />WIDOWED D1V0 (Sy dtr) 4t gr{p.y) h[r. I Dan Awn r4.:' <br />t Id F i,� s -z5 -lase <br />b47O <br />/4 BIBTE- (L1W. tov��ara.t� t1) k LL CCpIT�IZENRtO(} R'SA! <br />ar awr d �.rkias a avr N rxUr.d) 0i USTAT CS ir�ownti/ Wry. <br />. y. <br />e S1 o County rel�n U.S.l <br />r{ %, /` 'I IM NA" t6. NAPE OI BUSDA" Ol WA7 <br />k � � L n jn_ Mar afet Chambers ldarie Re enber LaDgeD ' <br />rfTn nown )fu r"'sl r node r.v N Mrs. N. Lan an Granadd rollannd. <br />(.). <br />- <br />wTioN tatr.r n:t <br />r f.l. (b. Bas a o.r Bas Dr <br />DIRECTI.T ""LNG TO DEATY� <br />•SAY yy ar ANTECEDENT CAUSiy 4e 041 <br />L <br />aA Yy'.aMw ru. .LOy . <br />r DUB TO fa)_�__.- ..�_... `y <br />R pT REE BIGNIT1CgliT ONDITIONI v <br />Con Nt4rrthe dinrit nrd/tl�rr�ia.irae �rr1 ' <br />n <br />I{►. YAJOE MNUjNG{ Ol OPERATION t <br />....z} .. T[ - Tr (3 N. <br />3U C D har4 IarA l.rtaq. •trrt .ppbCYS..Oa) ( Tarr ar.S wrlr EpRA41 We A <br />r t.. i ( > i Whl�lai6 I U�� IIL ROW DID WORT }c }t <br />y <br />niJl�ilti ,7. r. Na4 WWIe i Wet . <br />eea+ad aitve '�..�...,1� ,ant that death occurred ot /L:..+n.. ott the datf stated above,.. <br />�„ v. (Dejtaa r fteW DRre�. <br />, i a I;AI{E W CEhIET O T08 I ( br W-6 W 90 <br />�. 'poi' -DOAT <br />(ppplfyQ �'x.h) 9 3 �bI "' ✓ ene�'e.rtl _Has tinge.. Aebraske• <br />WWRAAV :NSRA��tttE(1lOR31�A,U" AD,HRO - <br />r <br />zt}nd e1 n <br />-lrosra <br />
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