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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF,.HE LT4-1 AN! Mt f1AN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE4[=BPk4 KC4'.DEAARTINE(JT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORS' pDR. vi AL RECQR DS." "
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />STANLEY S. COOPER=-
<br />- :AS ISTANy STAT,,E REGISTRAR
<br />DEPARTMENT OF REAM•;4ND
<br />';HUMAN SERVICES :*r, ?' ,._
<br />et � ;
<br />DATE OF ISSUANCE
<br />09/23/2013
<br />LINCOLN, NEBRASKA
<br />8
<br />o
<br />1. (first',: NOOK ::: Lola SiOk)
<br />Raymond Eugene Havel Jr
<br />CITY AND STATE OR VIRRIltletY, ORfo1SlsNCOUNTRYOFBRTH
<br />Tilden, Nebraska
<br />7. SOCIAL aECURITY NURSER
<br />508 -64 -0889
<br />ob. FAauT YIIAYE ,f oat brYboloo.olor softwood mob r)
<br />1823 S. Bla
<br />Ec. CRY OR TOWN OF DEATH(brbid. Zip Cod.)
<br />Grand Island 88803
<br />SE. COISnYOF DEATH
<br />Hall
<br />ba RESIDENCE STATE
<br />Nebraska
<br />SE. $WA!TANO NUR
<br />1823 S. Blaine
<br />11. PA11 $4NAME (First, Weida,
<br />Raymond James Havel
<br />10. EVER IN U.S. ARMED FORMS"? Oleo Orlin dwrMeoNUB. 14a: NNANTAANE
<br />Ira.. No, or Unk.) Yes 03/17 1973 Sandi
<br />ltd.
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<br />,
<br />CAST
<br />20 is FEMALE
<br />WWII* RINIR Year
<br />❑ Pregnant atum. at death
<br />❑IAA plaellrn. Oct plap,ad wlNan 42 dab* 44 Al W
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<br />3. DATE OF WAIN ¢b..D.Y Ya)
<br />September 11,2013
<br />S. DATE OF UWTH Mo., Dew VC)
<br />October 28, 1948
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<br />68803
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<br />® YN . ❑ ND
<br />tap NARITALSTATUS ATYWEOFDEATH IlMalbd ❑ Nwar lab NAME OF SPOUSE (Fin, 11101144 took sa1SlgFalb Owmwidw
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<br />12. ODTNER$.NANE (Fill, addle,
<br />Irene Ethel Day
<br />Madan Surnsme)
<br />HR. RELATIONSHIP TODECSp TT
<br />Spouse
<br />1E MOHO) OF
<br />Melaka Elnowato
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<br />Grand Island Clly Cemetery
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<br />Curran Funeral Chapel, 3008 S. Locust St., Grand Island, Nebraska
<br />Grand Inland
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<br />lad LICENSE NO.
<br />1tc. DATE (Mo., Day, Yra
<br />September 16, 2013
<br />STATE
<br />Nebraska
<br />T7b. Zip Coda
<br />88801
<br />CAUSE OF DEATH (See instructions and examples)
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<br />Us DATE OF11LIURY RNs. Day, Yr.)
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<br />221. LOCATION OFRU)RY,• STREET a NURSER, APT. NO.
<br />201404628
<br />DATE OF DEATH. (Mo., Dye: Yr.)
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<br />244: DATH 1f cIIED (Me. Day, VI.)
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<br />STATE
<br />13 27056
<br />246. MEEOF:DEATH
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