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STATE OF NEBRASKA e _ :;;; , , , WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF FfEACTH�A,ND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORICiI'�AL RE"CORD OtV FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICE5; VIT�tL�KECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. � DATE OF ISSUANCE ' ��it � O� �i+� � � u'S,7`ANLEY OOPER O�� O` �0�� V � AD�'F'ftRTMENT OF HEA TYI�D, LINCOLN, NEBRASKA HU�jAN,;��RVICES, ;' � c� ' STA28QFh�RA�CMD�ART�TfQPl�fAL28A1�IDHlAKAi+tiBR�IC84lIIYANGBMD�IlORT,` � ' < VlTAL s'tK[1S[1Cli c��tc��oF a�� 9 0 75 3 7 �.DE�T.�yE 7. � ►�tt'tE :SEX 7.DA Of OW�M MYnw GW Mirl �3� � Jtme 21 1999 t. AKDS�AtEOFBNRM Mro1hf/SA.nMM[auNyl SaA13E•WMMtl�y i1N0E�11'1E'AR NNOENt Y 0� M NM/L tyy R�aral H�ti2� Ct�ur►� �� 78 ��s � "�`� x� �"a Oct�r 25. 1921 z SO�u 9�umn r�B€n a w�CE a oFAn, ��28�—�. �+su. [� •wrr on�u � wanp�w�. ; �_�...-�. ��.�.,�.�..�.�� a EwG.yy�rM _ a �. �''�. �''1'dI1eT�.$ H0.4�l�.ti32. � � � drr7isciir....�,_.�. �c��v.ro+�bra Ecc�iwru �rw w a�crrr w�ts M COUNTv Oc OEnTN w14iriL �.�Za�1 �W.�Sna ✓r � N° . CL NE. -STATH 9E COI,MRN WC CR`/.TlMYNONLOCATION b BTIIEfTA/bNIMiFR Mprtlrl,�COaM !�IWOE IY�S � r�Teb�raslca HaZl crana I ana � �O i0. .�,p,YNW.BYtk.Am�e�inlnbN. tt..ANCES7RYN.q..M�f�n.lAqGn.tiM�Mn.�ICI t2�y MM11ED iM�00WED 1�1MMEOFI/OUSE n►WrpM�W/iniwwY .c:raoeea�� 'Jl�� Isw�rr IC1! � W/ Uanish "�° °"'OR�° Do�roth Jtuie I�unn 1N USliAlt3CCtJPRT10N 1QweAaiMalNpnrabe»a4aY,r+ncar /b KWDOfBUSMEA8MI0U6TRV 75.60UCA�10M 1 drW+v4 Mk w+rn��Mi�@1 � Production lanner New Ho i�nd �"""�"�e�',�� "�p�� tQ.FATFIEN•14lf�lE FNS'� i�MD01.E � lA3T �7 WOTWpt BIRST IIiRfOIE WIDEM T�Ciore tR WAS pECEASEp��Eq Ip U.S.AI�IEC FOACES? � .y,�Fqqy��µ7-�� rv..roar�.�.� ;n,raq�+...anae.raa�xv+oa� �11 II ,aa �,u�cwa i. i+o�ana+rowN.sr�lln�nthz Ji�s�e C,ra�d 511 Hoic�omb, Grand Isiand, Nebraska 68801 IC.EM�µMER•S10kAtINiE 6 Lf�E NO. 27a 11ETMOOOF p19PpgTiON 41D.QAtE 21c.CEAAEIERV OR CREAMTONv N�1A�- .. l�ot embalmed []�, []�,� June 22, 199 Central Nebraska Cre�ation �'F��.N� 21tl.CEMETEqY 0R Ci1EMATORY LOCATqN Op TOYM1 $TATE Kieine Funeral Hame ��^ ��^ i Gibbon, Nebraska 710.FUNEqAL 1WYE ADOAESS ISTR..:t Ow RF.D.NO..CRY Wi TOMM.STATE 21P1 3213 W. North Front St. Grand Island Nebra � �� 16NTER ONI,Y ONE CAU3E PER LRIE FOi1 ui.fD1.AND Iell � YiMrv�l�p��ny a�ln PARTX , � - i �� f /3 e�i?ic � -v � .oa �ca+ a � �w awwe.nn . � . � > _ ro� � . c ' i DtIE/0.9R CONSE�uE OF� �i ,r d� Cl �"� • ' � wrv�eM�narw�neew� JY�d�/y �/}•'rl /e lt�� • r i � ki a i/'` � J . i ' p��p qN5-fA�O�aiaWtirfwy�D�pyyp�M�4�rol�NM�f. PAPIIMiFFEW1lE WA5T/1EREA INTOPSY W��/y��p��K y /J/ .,, PREGHANCY W TNE PAST 3 MON1M8'+ p{AyNEq pp pp�pyElle T-`� i�K i0-5i4 YM No YM W YN No � 2B6 DATE OF NLiURY /AU.�M'�Yy 2Et MOUR OF N4iURV �EO.DESCRIBE HOW INAIRY OCCUAf1ED � 1 ❑ AtC'Of'M ❑ U^Oe1M;nmb �i ❑ `�"'�'a ❑ P"'a'�4 26f MIJURY AT WppK 2Et PLACE OF��N Iip1N.Wm.aFea�.hcb4 ?e9.tOCAT10N STIlEE7 ON R.f.D.NO. Gr1'OR TONRI lTAIE a�a a++�a�d spaYi Q �a mw�n ra� r�p� . �M i E Oi QEATN (Mp.qry.rr.l � O�TE SK}4ED /Ab.D�y Yr) �TMiE pF pb►7M E. aTUne 211 1� Sa. .OATE SpNED /Ab..qW�.l s TINE OF OEATM a�� Ptc PAONOINrCED DEAD /Mb OM Yr.r 21d.VIIONOIMICED DEAD /bi r , �� June 22. 1999 10:00 PM M ��`�� r �tt 7o1M.b�Md^N�wMCW�MMh urroaatllNtl�rN. e4c�aMMu�M �� 7M.Onl�rwf4puMwwnnrWan+MYMon.nmi�epnCMMoe�OM taueelalltilW. ,�3 /`� � MMM.tlM��n00Me��n00u�bMauMNsYYG ( �nC T � YM T� ��Tl7BAf�CQ U3E CONT T pFjITM? HA$ORpl1.4 OR 11S$�JE DONAT�Qy 9EEN Cqi$IpERED7 WAS CONl61T QqµTEp+ � YES NO � UNKNOWN � vE5 � NO � v�g � � �� .h�U��fEANDA�,OFCEATIF�AtP7rY OROpER'SGNv9k:WY6RCOUNTVATtOANEv� rT..,a�,�.0 Jane A McDonald MD, 800 Alpha St, Grand Island Ne 68803 �, nec+siaiw JZU OATE fIIED M AEfi1STNAR Ab-A�l nt JUN �41999