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Kenneth W <br />Walter F <br />Fuss <br />EM <br />Mach l <br />l -, 1 <br />tot A <br />U.S.A.. C <br />CITIZEN Of WHAT C • E <br />� � <br />NAME Of SPOISE O <br />Of Wk.' eiriirallolaa amt 1 <br />SECURITY NWRSER U <br />USUAL OCCUPATION (Give kind of work dim d.riag mod K <br />KIND Of BUSINESS OR steystri, C <br />COUNTY O <br />OF OWN <br />CITY, TOWN Olt LOCATION O <br />Of DEATH I <br />INSIDE CITY UNITS _ <br />_HOSNTAL (MOTHER I <br />INSTITUTION - <br />-Nam (O a« in &UMer. I <br />If MOIR 011'l14R1.1400401104. <br />0410141.011.4.: a.., • <br />•a Moos. <br />FATHER - NAME M <br />MIDDLE LAST M <br />MOTHER- MAIDEN NAME MET MIDDLE 44E1 <br />WAS DECEASED EVER IN U.S. ARMED FORCES? M <br />M4IOSMANT- NAME- RELAU0NSNIP— /AILING ADDRESS OHM OR LED. NO.. CM ORMARN. <br />i <br />STATE OF NEBRASKA <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH,IND <br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL,R67,011Q ON <br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL &CORDS <br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. j <br />DATE OF ISSUANCE <br />N0V 0 7 2013 <br />LINCOLN, NEBRASKA <br />201309078 <br />STATE OF IA KA— DEPARTMENT OF HEALTH <br />WREA11' MEAL STATISTICS <br />CERtIFICATE OF DEATH r .- <br />STANLEY. DOPER <br />AS$ZSTANT' RE'GT'.5 <br />DEPARTM IT OF"HEALi l"}AND <br />HUMAN SERVICES <br />