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1 • . UST Ga Gene Rallens 2. SEX Male 8 ma Co MAW AMM1 LW Veld Ma 30, 2001 a " QO. A IIgIMUSA_ RemoNAaN1 k •LaN- (Wel Ogallala, Nebraska f 65 t 1028 1 OF . .2.82 September 9, 1935 S0. TA08 , DAYS 5e. HOURS MIS 3 SOCIAL NEIAMEN 452 -66 -7286 Ea PLACE OF DEATH Norm: ❑ �FaaaM OTHER rg NI..I,H.M ❑ ERA ❑ RPPEM•ICA ❑ 00* ❑ oa,• 16.2 • RV•Name ONINPIENIENENTINSPNasd 4.MNi Wed . ewood Care Center Se CRY TQNN OR LOCATION OFOWTH IN INSIDE CITY OAT S Grand Island Y» ® Na 0 ea COUNTY OF DEAM Hall Ss RESIDENCE -STATE Nebraska w What Mao News. its COUNTY 1 Hall St CITY. TOWN OR LOCATION 2d. STREET AND NUMBER A1EAd0 Z,2Ca9N Grand Island J 2408 N. Howard 68803 k lW LAMS $48€C vs ® ) ❑ White 11. ANCESTRY fel. Wan Maawn. Oerm" NN *ears American IF In MARRIED 0WIDOWED 13 NAME OF SPOUSE Nada gmmisaw NNW i ❑M'' ( Betty Benisek 14a USUAL OCCUPATION lfi a aAecimak damMgmON of smog MI. men Wm21/2 Technician *10 KNNOOF SLIMNESSa0DUSTRY ITS EDUCATION ,00* Mir lgIN11jemti cony** ERPNINafya9Aamr, 10-121 11.atl Environmental 4 ears 1Q FATHER • NAME MST MIDDLE LAST Floyd Orville Rallens 1 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Lois L. Pocock 1N. WAS DECEASED EVER IN U S ARMED FORCES, IYAa+n.orvlal Jlvas anram Ye s 195 - 1,a 1/ANANT - NAME Betty Rallens 'MO INFORMANT MM.I40 A00RESS !STREET ORRF.0 N0. OTY OR TOWN STATE. 231 08 N. Howard, Grand Island, Nebraska 68803 20 - SIGNATURE A LICENSE NO X *//'¢3 21* METHOD OF 0122081,N ❑ate ❑ .. .... ❑ 210. DATE June 1, 2001 21e. CEMETERY OR CRIEMATORY - NAME Central NE. Cremation Sery 22a FUNERAL HOME • NAME Livinstston- Sondermann F.H. 212. CEMETERY OP CREMATORY LOCATION CITY OR TOWN STATE Gibbon, Nebraska. 220 EMMA HOME ADDRESS (STREET OR RF.0. NO CITY OR TORN STATE. 231 1'601 N. Webb Road, Grand Island, Nebraska 68803 -4050 NRi*D.A7F CAUSE TENTER ONLY ONE CAUSE PER LANE FOR cat. Mt ANO1c11 AMarval NgaNan Aral and Naaa1 . P�a+ CA'E TO. OR ASACONgEGUENfF OF ari NNeMeeO mem One Mar 14 ■ DUE TO. OR AS A CONSEOUENCE OF Maa.yM bemaA One* am/ Mum Iu , , pat named PAM ' R SIGNIFICANT CONDITIONS ' COeEArns b ps 21*2 al A /U0. ' -r ye / S- CART W IF FEM4LE. WAS THERE i 24 AUTOPSY PREGNANCY IN THE PAST 3 LW)NTNST ,r 10.2.0 n3-541 Yes 1 I eT. IN N. N. V 25 WAS CASE REFERRED TO UMW XEXAM.ER OR CORONER'+ Y. 26e Q A<CdNN 0 L, . ene0 0 SuNda L-3 + PendA9 260 DATE OF INJURY 0.03 Day. wi } 26c HOUR OF IN.rut V i 26e DESCRIBE HOW *Quay OCCUI.RED Y M ] - 72% E . L-J �'� � 9sI'e^ 23a DATE OF 26e KIAURY AT WORN We ❑ N O ❑ 261 AC MFMA ,,,..p, M y* %coml. LOCAT+O4 STREET OARED NO CITY OR TOWN STATE 1 . er � 1 ,..i I .r. I a p Q .5 Y DEATH Ma, Day Yrf I 21. DATE SIGNED .0.b LMr y • 2N0 TIME 02 DEATH 'May 30, 2001 270 DATE SIONEO Afn O Yrl May 3 01 X 1, 20 � 2 a 10IM 0a a 1sY A 0a41 0CCyrod {1 � 21c DATE OF DEATH pgGNOLNCEG corm.) !Li fly r. i Ad PgrJHrxA.(;ED DEAD FM 12:36am = i M . dm . dace an a1eW ! 2a. On wr ems $$ w M'r. arm n..t "y u0+wn death w.ae e 2 oc �. sI S me Mn. U0 One dace yq A.0114 e2*1.2+ Mad Swage and Tab k 29 DO TOBACCO r 31 NAME USE CONE DEATH? 0 YES II NO ❑ UNKNOWN AND ADCNE ^^ OF CERTFIER 30. HAS CU oRGAs OR TISSUE t1 ATION SEEN NASIDEREC. j 30 0 WAS CONSENT DRANTEO % j ❑ YEs c.2! 0.0 f 'r ❑ YES Z No (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY, 7ype0. P...K! 1)T Dr Jane A McDonald MD, 800 Alpha Grand Island,NE 68803 32a REC,STRAR n, I STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT,ONWLTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE - ORIGINAL R kQR ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERL4'CF5,�? I L'Rte,ORD.6 OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS... DATE OF ISSUANCE MAY 0 7 2015 LINCOLN, NEBRASKA CERTIFICATE OF 2 • TAN 0150301 DFPA�T A�trAfD °; hHUMAN SERVICES i7A7lMRt11111111MtMDlAtZ1lN1 7>N AND MIAS sums l liAM de' • VITAL STATICS= • 1,