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<br />TM --
<br />SOCIAL s. _ 1 TY NUMBII N USUAL
<br />12. a. w . a1
<br />1 3a.
<br />�'•' Yi.
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<br />x_ e
<br />•T : . ' (M.., Day, Yr.)
<br />3. lie 20. 1983
<br />ORI /D
<br />0..... Me.)(Sp.ei/y) (Vol.)
<br />wt •( 1
<br />OCCUPATION co. :. 4:.1 .r..r* d... darriag
<br />orkbag Ilk .e.. ifMif.d)
<br />- Penner Park
<br />E -Iwo Sw .
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<br />6
<br />• N
<br />WIDOWED. DIVORCED
<br />I c - Il rind
<br />mot KIND
<br />*rack
<br />1
<br />• DAYS
<br />ALARMED,
<br />(Sp.ci(y)
<br />Of BUSINESS OR INDUSTRY
<br />F
<br />HOURS
<br />/0
<br />1
<br />.
<br />NAME
<br />11. Mar
<br />2-.
<br />Y DATE OfORTM
<br />MMNS. ( Day. Yr.)
<br />f Nov. 28 1.1
<br />SPOUSE ( . B)VS. al.)daw w...)
<br />an Lill.
<br />CCOUNTY Of DEATH
<br />I 1 Nall
<br />CITY, T O W N OR L O C A T I O N Of D E A T H INSIDE CITY WAITS
<br />(Specify V.. No)
<br />ti • o Uc. Yell
<br />HOSPITAL OR OTHER J INSTITUTION - Naas (If not ;..;Mi.r,
<br />.
<br />IF NOV. 0E MKT. Mrie.e. DOA.
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<br />RESIDENCE -STATE COUNTY
<br />13.. Nebraska lab. Hall
<br />FATHER
<br />CITY. TOWN OR COCA STREET AND NUMBER
<br />Ise. Grind Island isd2210 W. Oklahoma
<br />INSIDE CITY LINTS
<br />(Sp/00y Y« or Ne)
<br />15..Yes
<br />-NAME MIDDLE
<br />WAS DICEASED EVER IN U.S. ARMED FORCES?
<br />(Y...... a will)! (11 rm. ,iv. wow ..d dews .4 AIM(*)
<br />IE.
<br />LAST
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<br />INfORMANT- NAME -RELATIONSHIP-
<br />1
<br />rMOTHER -MA MAMI 1*11 Mf60LE LAST
<br />V Nedews
<br />MAN.ING ADDRESS (STREET OR R.F.D. NO., car ea TOWNJTATE LIt•)
<br />Je
<br />.
<br />BURIAL. .or.I
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<br />.Irei T
<br />.
<br />b. 23, 1983
<br />NO. 9. 3 y r
<br />CEMETERY OR CREMATORY - E LOCATION
<br />20e_ Grand Island Cit rod, Grould
<br />FUNERAL HOME -NAME AND ADDRESS (STREET OR R.F.O. NO.. CnY
<br />. s •.•)t . J. I
<br />ITVORTOWN S1A
<br />Island Ns
<br />OR TOWN. STALE, I
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<br />111
<br />DAT.•OP (M.., Do,. Yr.)
<br />23.. - 2- C ' 3
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<br />01 s IMKIAN.
<br />COUNTY ATTOWEY
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<br />r'J T
<br />• (Mo.. r, a)
<br />24..
<br />r<. ■
<br />: DEATH
<br />24b.
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<br />• '• (M.., boy, Yr.)
<br />2 b . - 7 - - v - -
<br />HOUR p �
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<br />PRONOUNCED DEAD
<br />(Mo., Day, Yr.)
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<br />A ..II� . .d
<br />c
<br />.._, • (1041 IAN. . ' ' OR COUNTY ATTORNEY)
<br />I. ... ,n• .•.- .• • ... . r . .• .
<br />_
<br />PATE REC D SY REGISTRAR (MN., Day, Yr.)
<br />lia. (fid..ew.) s /*'` 24& / -47/4‘..??..'?-/t.,‘ - 47/4‘..??..'?-/t.,‘ 1 r (�
<br />► 27. �
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<br />IAi*EDIA1'E GWSEE�
<br />0# ONE PE UNE FOR (o), (b). AND (c)1
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<br />PACT b.e..« af...d ANNA I M ___ , .1,41'.4- as --.•
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<br />• A r ' ENCE Of: . M'.n al b.N...n «7 /ow l ANA
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<br />DUE TO, OR AS A CONSEQUENCE • • / + Iw...,o1 b...•.ee
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<br />Yes 0 N. O
<br />AUTOPSY
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<br />I WAS USE REfENNE0 TO
<br />EXAMMVER OR comm.
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<br />24.
<br />AC SUICIDENONCOM
<br />OR .040.46 NONCOM 46 .4VESTIOATION. (sow
<br />30a.
<br />NUM
<br />URY I.
<br />DATE Of NU.., D.. Yr.)
<br />(M
<br />30b.
<br />N Of EWRY
<br />30e. M
<br />DESCANE NOW .uuay OCCURRED
<br />30d.
<br />AT WORK
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<br />.041.. WHIN... M:. (S..c.fy)
<br />30..
<br />LOCATION STREET OR 1.0.0. N.. CITY OR TOWN STATE
<br />30a.
<br />STATE OF NEBRASKA
<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 ORIGIM4L RECORD ON
<br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITACRECORDS
<br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />STANLEY;1COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES
<br />DATE OF ISSUANCE
<br />IAN 13 2014
<br />LINCOLN, NEBRASKA
<br />20140,0442
<br />STATE OF NfNAIKA- OEPAIIT OF RREALTN
<br />NOM OF VITAL STATISTICS
<br />CERTIFICATE of MTH
<br />63 02031
<br />
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