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<br /> � � .� SE% � � DAIE Of DE�TH �••o��", . . .
<br /> �oecE..seo—N,u..e •�•" •��,� p�.eXsxider , Feutale � April 28� 1977,� �
<br /> , Glenrose
<br /> � ��i��w�H w . AGE–♦ DA1E Of SIFTN i����o, o.• COUNTY OF OEATM .
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<br /> �OR lIXAT10N O�OEAiH � MOSFITAI OR O�ME0.WSTITUTION–NAME��
<br /> CrtY TOWN s�t��v ret o��Na � .
<br /> Grand Island �, Yes �� St. Francis Hospital „w„.c,...,.p�N.Mt
<br /> �T � NEVER 1MRR1iD, SUR'/IVING SPOUSE� .
<br /> .5^T �. .r i„HC���u>.�.,rn.�CITIZEN Of WHA7 COUNTRY MARRIED. �.`�r�� �-+ �e�.naPrr . � .
<br /> co�wn�� . wiUUwfO.G��OFLED� �,a�{ '_�.— .
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<br /> ;SOC�AI SECURIrY�NUMeE0. � USoUµL OCCUPATIONA ew���«o or�.o��oo�+e ou�i�G+si or KIND Of lUSINE55 ON INDUSTRY
<br /> W •.�����.Homemaker 'i�m Home
<br /> �,�t � �� �y. ' ir n��.iµ STREET ANO NUM6ER c�a. ,
<br /> RESIDENC –57AiE � COUNTY GITY,�OMM.00.40CATION �>recD��� 241 South Vine J Y• � �
<br /> Grand Ssland ,,, Yes�,,.
<br /> ��i�Tebxaska ��b Hall �« ,..� ,,.�. ..,00,� ,.��
<br /> MOIHEY–MAIDEN NAME
<br /> F�,"E"—"""^E . " �""` Katherine Montgomery
<br /> H�• gqui,er ue ,.o �o.<, o••�w'68803
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<br /> �.II.WAS DECEASED EVfR IM U 5.AWtiED F02CE57 INFORMANT–NAME–RFlAT10N5MIP–MAIUNG ADONE55 Grand„Island,Ne/ � , � � .
<br /> a .� �,T���„o.„,� tn r..,9�...e,o�a ae,..oi..••��•� �.r^rsu�c J. Alexander—I3USbe.rid-2�41 S.V1ri2�
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<br /> � ��f0 CAUSk GIV[M IN�ART Na) YES❑ NO O 11� �„0 1 ,M„' . ,
<br /> � MOUR NOW IN1Vki OCCURNEO��"���^w����oi iw�u�r i��w��i O�i.a �, � . � ..
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<br /> •UCE Of INIUNY.�nore,r.� , .ei. .c.o... LOC�i10N .
<br /> ' INIURY AT WORK �>recin i � �
<br /> ':.1 r 1f�o. o�� o�r�<e�ioe.lu. 7p .. . . . .
<br /> 7M. .� � � � �w0 u w rr/ne��� �O �0�0/0;0 nO�.i�^ ! OryAT��L11t�tD 0= D<t'pW+ .
<br /> � CERIIFIGTION– .^'�". on� �oor� �"v N � / �ort�i c�����f � � .
<br /> ♦M SIC�n�.� �in �� �� �TO rOw n �� .-�^� ]I�.�OH �� C�e�� tido � e C.T ]I� M lo � .
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<br /> CEIITIHER�–NAME nre o�enwn M D . h� `Q ]._ N`�L ]k. .
<br /> ».. o. o ~ <�"o.aw'�sland � 66a01
<br /> .AUIL/NG ADDRE55–CEN11f1ER .. "�2 •TZorth �ust r Gran wN s�r.�i . . . . . . � .
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<br /> '�6VRIAl,CRtMA��V�+,k v•�+• «ufT4ev OR CREAUIORY.–.NAME . � T'r;
<br /> �..����� �v�� Grand Island
<br /> r�.. ial �o Grc3nd Island Cit e � .o. . -
<br /> ..DAiE ira+��,o fVNENAI HOME–NAMF ANO ADOPE55 ��'� � . . . . ,
<br /> �� =u " TS�. ZVZ S�i � ' O�tF�fCE1VlD�Y IOCAI�fGI51AA� � . � � .
<br /> l�no NEG�STRAR–SIGNA7VRf I�b . . .
<br /> EMBAVAER S/GNA7URE<<�CE�NB:NO / �yy� 1 /� `7� � .
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<br /> W&EN TH�S COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br /> S�TjiTE.'�DE'PARTMENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE ,
<br /> �, -AyTRi���'�OPY OF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br /> ''D•E'�P.E�R�MENT OF HEALTH, BUREAU OF VITAL STATISTICS, WAICH
<br /> `'+i' �YS�°�,'F1E"LEGAL DEPOSITORY FOI: VITAL RECORDS.
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<br /> DIRECTOR OF VITAL STATISTICS AND ASSISTANT STATE REGISTRAR
<br /> LINCOLN, NEBRASKA _ Issued May 13, 1977 __
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