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S�„o 1a .� � . <br /> �CITY,TO N,OR L ATION DEA7H�:� oi<m�i MOSPITAL OR OTHER WSI1TUTtON—NA/wE i� wo�i� ve a nfr�vo Nu.n�l�i . �. <br /> n � PniFon a �. . �v` .o ». .. . �.J C � /�_ ,.,.�. . <br /> STATE Of.�INTH�� .o� +u s.•.,«wi CITIZEN OF WHAT CO NTRY . n�wRkIED,NE�EyR RRIED,. � SVMVIvI��—G 5ip45� ,c� of r �� <br /> I I . .. �ouwt.rr . ... .WIDOWEO.�OIVORCED�srtc�r.� . . <br /> SOGIAl�S URITTNUMBER . + �. � 10 �(� __ 11_����____"_ __'_._ . <br /> USUAI pCCUGATIpJ G t o or vro��oowe ow��+c S�or 1(�ND Of 6US1NF55 OR INDUSTR'I � �� <br /> . �� . avo�rir1G[�ra.fvew i�}rt��[v r � . . � � . ~- . <br /> 17 . .. . IL. � •. . . � '�G� IJE. �. . . . . � .. <br /> AESIDE —STA E . OUNTY�� �CITY,TOw'N,OR lOCA710N �"���<< ��— � � � <br /> ki»� STREET AND NVM6ER . . <br /> � . . . . . ret�e���a�o�• � . . . <br /> �m ���� 12P.�IJL�� �o. �Q.�..�. u< �CCLlJGO � iaa� p„7 o u. � � � � � <br /> .fA7NFR—NAME r� e ��s�. MOTMEA—MAIOFN NAME i��st wout � . <br /> Is. � �Fl[.2P/J� 202 6 �Lt PILA �se � � (/�QJG[ it � <br /> i/WAS OECEASED EVER IN U-5.ARIAED FORCES4 �NfOR/we.Ni-NM�E—AE1A710N5H1I—MAII�NG ADOAE55� �s.aee�o..r o no �+o.�cw...se..ie,ii <br /> IY�y no..or uiikna..n} t�l Y��.G�•��o.ond do���el��rr�wl ,. � . . <br /> n.o �,:J.0 ' �ced u.i.enk—dcw. e�i :Z.rz .L o 68 24 <br /> :DARi 1. � DFAM WAS UUSED!V: � �ENfER ON(Y ONE CAUSE VfN UNE fOR(o/,(b),�NO(q) � �«owe,.�.o oe <br /> { II �.+wo� S�sf � rwtF . <br /> . . ,n � � I� J � � .. . ' . . <br /> ��, �(�'CB-tC '.C }LC "b(�l�.4.0�[� -:. G. r-x�1-ry�-c � — <br /> . � ��... , <br /> � ! <br /> � .� <o C 'o I ob'. seoue�ct or. . � . � � . — — . . <br /> �oI` <.�ft o.o��s w to« <br /> ��¢<��ae��i� <br /> . . . .��� � . . . . . . <br /> ��Rf II. OfHf�SWN�tICANT CONDIf10N5�.COMDIt�ONS COMT�1lUl�NG i0 DFATN�Ui NOI REIwTED I�RT 111.li iFA4l[.W/�5 TM[t[A AViOPSY IF�YES M'!�f���+D wG6 CO�+� <br /> IO CAUS!GIVEN IM rAtT Na) . � fRfGHAMCY�N iNF IAST 1 _QNiM3] �� Oi�� SiDe�0 011f�r �wG C��3[ . <br /> ' ' TFS Ci ND� Itif1 � � IM P � . . <br /> �ACCIDfIVT,SU1ClOE�,NOMICIDE, A F INIUNY �rO..tw,o.r,.e.i NOVN � � MOW IN/URT OCCURRED' � � u+�Or�r u• ���O�r.i.'�,rr<w�a <br /> � OR UNOETE0.MiNED�frec�n� . � � . . ' � �� . . � . . ' <br /> ..�. . .. . . . . . 701. � 70�. M 700 . . . <br /> INIUNY Af�WORK ►UCE OF iN1UYY.r�ou�.�.�r,s�uer,�.no�r, IOGATION i�t�te�o .r.o.wo.,<�n o�ro �,i�.n i � � � <br /> �IfH<i�t���{O�w01� � ON�C[�IOG..fIC...I3�K�tt� . . � . . � . . � � .. <br /> �. �0��.�� . . . }a . . . . � 70y . . . . � � . . <br /> CERTIFICAII�N wow n o�e rlw� rONiH r •e.� �� us�aww«w/n��• v�pw i eio/c�o«o �h! DEw�ti�OCGUIl�lD . � <br /> ��M SIGI�N: . . :. ? tO . rOra�h O+r rl.� •OO t DE iwOu11 � N>C�P t ti� <br /> `, y— DG OYf <br /> it. o u,ioi.o,`.�. j I ��7' —'•5.7 7n • o..�j�� ti� Z�ZJ"7� ` Zu/�/ , ~. ti.�./ '/" en � �e`c:�as���.,eo. � <br /> � CER71f1UTIDH 'inEOiCnI E%AMINER OR C00.0NEq o«��ne�+s.�o.*�t ..o�Jor��y �� t<eoa��w.a rw p^cto . .e.� � a� . � � <br /> w�l�Ow D �OD��r�D/O�tH��w�Iftp�ibr� � f w <br /> D M�OCCYI I M�D��!�n.D OYl 10 Ixt C�uil�l>>1 + // •p <br /> 17 � � � M.I11 +M <br /> GElTI/1ER—NMIE��rrl o�ru..n 51GNATVRE j- �,_. oa4 e o �uyeT�/ DA�51GNFp i�}n_r,. <br /> �" ». d W. Harb :xi r ' /%1� � �o <br /> ♦u41NG MORESS—CERIIfIER . . . a��ee�o�i.r o. ' . C ei`�q.+n . . C :.�y��� .���.�_. �. .. <br /> . 1k � � � ' �� � <br /> .6UR{�1,�<REMAT'ON,qEMpVwI CFMETERY OR CREM�TOQY—NwME � LOC�TION ' �� c�n o.�ow.. >r.�t� �� � <br /> ��n<�n� . � � . . <br /> 11. N1.� CG 7��. � . . . . . . <br /> OATE � �w�piiw,owr,♦ FVNEMAI NpME—NAME ANO ApORE55 �s���ri .• .HO.,[i�r o�ioww,s i i . � � <br /> � 7M� .. . ]S� �� � � . . <br /> EM6AtMER SIGNAl�1Rf{UCENSE NO � �✓. REGISTRAR—S�GNAIVrtF � o��f�ecfivt0�Y loC�l�EG�;fAw• . <br /> 756. <br /> � �� . . . 7�a. / n +� )te <br /> +', ��< ` � ��L..C�..'(��Al �Zl'�,L_..- . . �—�. .�� . �. . <br /> : ,' ' <br /> �E. ',Jr . . <br /> , i� t --,,--.-•.-�__:�._�,- ----- _ . _ <br /> � �,. �" ,,,.WHEN;THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA <br /> ` bSTA�T�,�DEPARTPIENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE <br /> `rS Ar'�I�„�I-E' COPY OF AN ORIGINAL RECORD ON FILE WITH THE STATE <br /> �'.�,,�" "p.E`��$TMENT OF HEALTH, Bi7REAU OF VITAL STATISTICS, WHICH <br /> ✓� " �" .s:THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br /> �r�%°5 0 �, � <br /> _ � --+ '�or"n,L.�..� <br /> , ; DIRECTUR OF VITAL STATISTICS AND ASSISTANT STATE REGISTRAR <br /> LINCOLN, NEBRASKA issued August 18, 1977 <br /> .. :� <br /> ..� � <br /> _ � �,�� <br /> � * � � �a <br /> '�� <br /> �y,", <br />� _ � ` - <br /> � <br /> � L � <br /> � <br />� � <br />