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`fi for ree " � <br />rin Boot of `" , s ,i��'� ,;�', <br />sec_ T <br />tlflCeEOa,. hall- Gftaaty�l►e�tas#- n /o ";_____ <br />1 <br />■ <br />E -ST STATIS Or NWAAS"' " <br />w»iJulsxtAtr2�. DIVARI'M TNT OF RZALTH <br />SIXTH NQ. ) a111EiLt EIi 1'litEl $tstilMiq' <br />1 6...,....- CERTIFICATE OF DEATH &TATz TrLx No ............. ..:... .....:. .......... <br />1. KAt t N MTN 2, VSIIAt WMQ{IICE (tllw t rs..d Krd f/ rwN.IwwA Rrdw.le Ken eiiriw) <br />B. COUNTY �:""_�Q' {4`� _ - 4 STATt N4 b COUNTY <br />R CITY, TOWN, Oe 19GATIOR t. LEIKTN O! STAY {R 16 t. CITY. TOW14 on LOCATK)N <br />K " 12 4"" <br />d NAME OF i (q ad in As►pLtl: /iu NfM t/Mr0 d. STREET ADDRESS <br />NOSMIn DIN; - ' <br />INSTITVTIOR� 90041 �I� NO.tzs�C �Nw, <br />t. I$ PLACE OY.OEATN INSIDE CITY LIMITS! YES (Mob (3 t, IS RESIDENCE INSIDE CITY LIM173E Y[!� j. iAIIM 11E3)DEl10ET YES NO <br />Ad <br />Low wer <br />(�'Ft M JM)Ni '94 Rti1i ScAd4* - DEATH AUwA to I <br />S. UK E COLOR OR RACE 7 NARRIED Q NEVER MARRIED tt of SIRTN !. AGE UN /strf / IAIDEIII YEAR IINBEf kl Itai <br />�J�� � la/ IMa) M JTew Mh. . <br />^'cite WIDOWEOfX DIVORCED <br />Wo. USUAL OCCU►Ap oN (Cliff kind 0/work low lob. KIND BUSINESS OR INOVS� W%ACE ikate er #"*N CINIAWN) 12, CAT T Vf <br />du• 009 �( ap iM h/e, tfe■ iJ retard) <br />0414 #0tfa aK kolEw 11•. iATHER S NAME I)+, MOTHER S MAIDEN 14. OMAN OF HUSBAND OR wilt, <br />G%f l,Ll,alt� &41;" /yo the C4*44otE I &t+400i 4 9 e d �L�if �i14 <br />IS WAS,TxCEA 0 EVER Ill U S" ARMED ST. Is. WCII%AL SECURITY No POOR"" . <br />t Lf..e'I YO er±M Lyle l K,. e.w w s Mir �/ rnW No'w Y t'N A* o tE tAIII ' tEkfd fall am tease j lice fio, (a). (A). eAI (t) � f INTERVAL ELTWELR <br />PART 1. DEATH WAS CAUSED BY! <br />•pN(�}(� AND OGTM <br />IMMEDIATE CAUSE (a) <br />Condirfonf, Ilan /. DUE TO (k) <br />rAtik pow r' re <br />eDast caure�e). <br />/altA0 eat <br />the under <br />is.. DUE TO (e) <br />ll1Al (. <br />PART If, OTHUI S16NWK:W CONDITIONS CONINNUtTYA TD DEATH ka No RELATES To TIN Ttletlllk► DREAM COIOTKOH GIVEII w PART I(s) <br />Q F 2%, ACCIDENT <br />Ak <br />20f TIME oi' <br />p s Iruuar <br />SUICIDE <br />HOMKIDE 2(M DESCRIBE NOW INJUsir OCCUARE"O. (Eeret aotwe of iajwl is Pets i r Pte t/ of keel rd.) <br />tfuer 1(dunth, Der. Yew <br />a. M. <br />P. A • <br />It. WAS AUTOPSY <br />PtRFORMEDL <br />YES ❑ 110 . <br />1 20d INJUNY OCCURRio 24t. ►LACE OF �KJURY (e. 0 In or d»Mf bRY, Of CITY, TOWN. OR LOCAT KIN COUNTY STATt <br />•+ WHILE AT ❑ NOT WHOLE ❑ /a M, Jedw►. Itrtd. gpwt Will dt.) - . <br />WORK AT WORK f I <br />attended the deceased from _ , fe an/ last a• MAIN <br />As on the date state/ above, and to the Seat of any Anor)►Ide, from the comet state /. <br />e rj lie MONAT (Dreret or (kk) 77A ADDRESS Zit. DATE SIGNED <br />a 23a BURIAL. CREMATION. ` 2 DATE 2h. NAME Of CEMETERY OR CR MATO" 274: LOCATION (fill, (ore, of teeal /) (ask) , <br />� N >t[M AL ( tIm � ^1 /I �_ Dos+.phaf+l C _ � � . Do'tiy'ltan, Nsb�a.k�t <br />2E. DATE R CD BY REG47RA- T25. REGISTAAA S SIGNATURE 2A. NAME Oi MORTUARY <br />ADDRESS <br />prt.M Ne4t A. �'tu�o.: Es Mo #aea tt�� KEN, NF t c. <br />County of <br />f <br />C State of Nebraska <br />On this ......9.th .- ...... day of ... 11%TACA ... :.... <br />...... .. . 19.. 3.. <br />.......... ... .... ..... ........ a Notary Public duly appointod, commissfoned.and qualified <br />.;;r, <br />y . or kjandf F}a, nr the said county hereby certifies that the above is a true and exact copy of the Certificate of Death <br />i <br />t�. <br />.................................... <br />are <br />whicn has been filed with the Ragistr. <br />"i3 a Go>♦H'c fIRK ,� - .; <br />., ..c► a t(dry j410,83 iny� hand'and seal the date last above written Q <br />�rr��I j N �� •'f �f. 'r.�............ Notcu ..Public ....... <br />