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<br />� q Q STATE OP NEBRASKA–DEPARTMENT OF HEALTH � � �
<br /> � 78� O O�7��" BUREAU OF VITAL STATISTICS . �
<br /> CERTIFICATE OFDEATHIC4/5
<br /> . DECEDENT-NAME FIFST MIDDIE UST SE% DATE OF DEATH f.No.,Oay,1'r.J
<br /> , � Walte�penbura � Ma.le ,April 26 8
<br /> RACE-(�.g..Whil�,8 a�4.A�nrriwn ORIGIN/OESCENT(e.g..Irelion,M�.icon, AGE-io.r e�nAdor UNOER 1 TEAR UNDER I DAY OATF Oi BIRtH(Mo.,Dor,Yr.)
<br /> .. Indian,Mc.!(SP��ifYl German.a�c.)lSP�i/Y) v (Yra.) MOS. .- DAYS HOURS f MINS. �
<br /> t•Jhite s American ° eo 66 Gb_ ' 6c. ' � Seb• 25` 1911
<br /> �, GTY AND STAtE OF BIRTH(1!nor in U.S.A., CI712EN OP WHAT COVNTRY MARRIED,NEVER MARRIED, NAME OF Si0U5E(If.�i/�,g:.e moidsn nom�)
<br /> �, ounlry) WIDpWED.DIVOFCED(Sps�ily)
<br /> e��� Graaid Is�and. Ne. v. USl� �o_ PIerried �,rlildred H_1ma ��hitaker _
<br /> � SOCIAL SECURITT NUMBER USUAL OCCUPATION(Give Yind oi�.o.k don�d�nny mos� RIND OF BUSINESS OR INDUSTRI' COUNTY OF DEAiH
<br /> Iol.ork�ng lifa,r.�n Nrsrir�d)
<br /> ' ,z. 506-09-623:(,_ I�aa. t ' ��-� ub. Y17�ni ri��l �.a. aIl
<br /> CITY,70WN OR IOCATION OF DEATM INSIDE CIT'UMITS HOSPIi4l OR OTHER INSTI�UTION-Nome III nol in��rl�ar. �f MOS�O��HST�i.a�a�.UO�.
<br /> 1 lSP���lyYa orNo/ 9:•� •londn mb 1 ourpe��..VE.... x.. �.nrf5p..;Ir!
<br /> 1�6. (1 I�c. l�d.'I V��� IIa. .
<br /> � MESIOENCE-STATE COUNTY CITT,TOWN OR IOCATION STqEET AND NUMBEN y1N51DE CITT lIMi75 �
<br /> � lSPe<�fY Y��or Nol
<br /> �saTJ 136. ISc. ���_1 ise. 9th St. u..
<br /> A HER-NAME IRS MIDDLE UST /nOTMEN-MAIDENNAME FIRSi MIDDLE lA
<br /> IA. '�j"l_ g I {\CIP�i(L__ HA'PIjP't`S
<br /> WAS DECEASED EVEA IN U.S..►ItMED FORCESP INFORMANT-N4ME-REtA�lONSHIV-MAIIING ADDRE55 �S�aEEi oa R r D r+o..C�nA�O�R�.dJ.�li,Zi�l
<br /> fv��.no,a..n�ne�i ltl r.�.v�••.a.en�e..r..o�....ia. 1V OOIJl �
<br /> � is. iv. . gy T.Si l L_„ir_���c�nbur�4lj fP–1 l8 F.9th tit.. Gra_nd Tc_l�nt9 �
<br /> � BURIAI_CNEMATION,NEMOVAI DATE CEMETERY OR CNEMATONY-NAME IOCATION CITY OR TOW STATE
<br /> xoe. ' . �ob.�� zo�. _�r�nr� T_�'i�,_ri�(�yt Isoe --- (:rt3.nA �fsln.nd � .
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<br /> EMlALMEP-SIGNAtURE 6 LICENSfy1�. 1� iUNERAI HOME-NAME AND ADDRTss (SfNfEI OM M�D.NO.C�iY OM TOwN.ST�IE.t1Y� 88a1
<br /> z v ,.;1�, 7, livinfr,ston-5cnderman:�'s,5U5 l�.k:oenig� Grana Island,ile/
<br /> le�M b«t N�nY 4ne.IWp�.d�a x��r.�A or .�•..�,do��o.d p o��und du����--r—�p..M�b e��ol�.tlo.�ina��an d/o.in . . . drorA d o — .
<br /> a,.�.�.re..e. � �W �.�..�. a�.e. <�«.e.e"e.{.�� '��ti.��.�p�/) � .
<br /> V y 330.(Sivrol�r�eM I�N�1� f-p0 74a.(S�0•a�w.�a..d l��I�l�A/ lTLL'��\�V��1/����__ y f..i� . � � .
<br /> OATE SIGNED(Mo.,Da�•Yr.1 MOUR OF DEATM A IZ'A€G(Ma ba�. r.) R�ZTK-D�AYA— V
<br /> 6'^t$ ✓ �9��� /� �
<br /> �r� 23b. 77<. M Wz z.b. �yt� �__ :,�. 0—�--
<br /> s` VRONOUNCEOOEAO(Mo.,De�.Yr.) PqONOUNCEO DE�D(No�r) V p0 PRONOUN�ED DEAD PPONOUNCE E D(Mour/ � �
<br /> p e lMo..OaY.Yr.) c n�] �
<br /> 13d. 1J�. M�_ 1�d�/26/7 �� . V'GG A M
<br /> NAME AND ADDRE55 OF CERTIFIE2�PMTSICIAN,COMONER'S PMYSICIAN OR COUNTY ATTORNEY)(fyp� F�inr)
<br /> REGI SBll-� Pri�f�_205_{pC�S_t��.oS�€ce�_�o B�Ee�is��S13t1d rr..NE . . .
<br /> ]bo.lS:Y.or...)� ���� �13Eb.'i�����..v"u y�ti..:en�.r ow
<br /> I7. IMMEDIATE CA �!- fENIER ONI ONf CA SE IINE fOR(e),(b),AN (�)) I � d d.e�A
<br /> PART
<br /> 1
<br /> ��^, p�n ien - -- , ��mmediate.o F
<br /> OUCiO.' NS . �ti -
<br /> Ibl
<br /> �DVE TO.OR AS A CONSEOUEN�E Of: � { I.r�no1 b.e.......��a.d e�oM
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<br /> IJ
<br /> pA�� ME� 1GNIfICANT CONpItIOMS-Ce..d�rwn�ao.�.�burinv b dw�„bu�no�.�Ia�M �N!f[/��lE.w�T 1MEME♦ �UTOY3� �5 Cn.iF�Eff�YfOVTO/�lD1C�l � .
<br /> � CY IM lHf V/.S J mONf1151 lSp��.l����o•�ael I E%M1�Nfv O�CO�O f•
<br /> n ::icr. r.,O Ne!; rs�...y...e...o Yes
<br /> I ae. Nn ,av��
<br /> .KCIOLM).SUIG�OF.MOMICIU[.UMOFT., DATE OI INIY�Y(Me-,De�,f•.l NOUY Oi IN1UY� DESCMilE XOw�HIURY OCCU�IED ' � .
<br /> O��lNdHOINvlSTIG�T�ON.ISy..�l�) ,
<br /> 70a. ]Ob. 30�. M �]Od.
<br /> WUtY�T WOtlt ItACE O�IN111fY�Iu Mow�,le.�..�n��r,lo� y. �IOCATION STRFET O�Y.�O.No CITY 01 iOwN STwTE
<br /> !Sp«i/�Y��w Ne! ell:<r b..ild�ny.�4!Sq<�I�I -
<br /> 30�. �/. JO
<br /> , ..-...�.:K'•�x;'w�,� __
<br /> WHEN TH=S�.Cij.��?`.EA�tA°Z'ES THE RAISED SEAL OF THE NEBRASKA
<br /> STATE .1�'�PA`itQMEl�f�',?QFr�'�.HEALTH, IT CERTZFIES THE ABOVE TO BE
<br /> A TRU�E:-.L`6P3C�,=UF'`AI� O"�IGINAL RECORD ON FILE WITH THE STATE
<br /> DEPE�RT'']�S�T'OF HEA2.T�,- BUREAU OF VITAL STATISTICS, WHICH
<br /> IS T.H 'I:�GAL DEPOrS�bitY. FOR VITAL RECORDS.
<br /> M A� �\; '� ;c , . �
<br /> . ..�.- ,..... � _
<br /> DIRECTO&,',b H .; A2ISTICS AND ASSISTANT STATE REGISTRAR
<br /> LINCOLN, NE RhSKA-'^"`�" I ssued May 16, 1978
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