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DECEOEli4 - NAME FIRST MIDDLE LAST <br />{. Clifford Jay Cooper <br />SEX <br />2. Male <br />DATE Of DEATH (M... O.Y. Yr.) <br />3 June 12, 1987 <br />RAC— (..R.. whim, week. *moats* <br />le li.o. NtJ (Specify) <br />.. White <br />ORN IN/DESCENT(..R.,N.t«e.,M..ie.w. <br />Oen.M. Mc.) (SNOW <br />s. American /4 <br />AGE — I... SiobMr <br />(Frt.) <br />saw 73 <br />UNDER 1 YEAR' U • 1 DAY <br />DATE OF <br />t . July 14, 1913 <br />MOS. . DAYS <br />a.. <br />• : MINS. <br />s: . <br />CITY AND STATE OF RIRTH (N eN ie U.S.A.. <br />*ems c...eryl <br />R. St. Edward, Nebraska <br />CIf12EN OF WNAt COUNTRY <br />,. U.S.A. <br />M NEVER MARRIED, <br />wtoowED DIVORCED(Sp.tify) <br />10 Married <br />NAME Of SPOUSE (If wife. Rf...widen n...) <br />t1 . Della L. Olson <br />SOCIAL SECUMTY NUMRER <br />12. 540 -03 -6478 <br />USUAL OCCUPATION Mb. kind el work d.... &eine mest <br />.verb., AIL .wee Nrelived <br />13 .. Captain NE State Patrol <br />KIND Of BUSINESS OR INDUSTRY <br />Nebragka State 9/0 <br />13b. Patrol uepc. <br />COUNTY OF DEATH <br />1r.. Hall <br />CITY. TOWN OR LOCATION OF DEATH <br />1 , w . Grand Island <br />INSIDE CITY LIMITS <br />( Specify Yen No <br />1.e. Yes <br />HOSPITAL OR OTHER INSTITUTION— Name (N net in .ifi:.r, <br />pica stone bed <br />1.d 520 S. Broadwell <br />M NOW OR INST. 1.rkete DOA. <br />OWpotonnil.er. Sw.. I.N1i... <br />14, , <br />RESIDENCE —STATE <br />1s.. Nebraska <br />COUNTY <br />1sb. Hall <br />CITY. TOWN OR LOCATION <br />Ise. Grand Island <br />STREET AND NUMBER <br />isd. 520 S. Broadwell <br />INSIDE CITY LIMITS <br />; -Y ea NO <br />FATHER —NAME <br />Is. Lee <br />MIDDLE UST <br />- -- Cooper <br />MOTHER —MAID <br />17. <br />N NAME FIRST MIDDLE kW <br />Hattie - -- Darling <br />WAS OECEASED <br />ITN. no. or NO <br />it No <br />EVER IN U.S. ARMED FORCES? <br />01 1•e. r"• hoe ..d ANN e) wn.ic.) <br />INFORMANT — NAME — RELATIONSHIP— MAILING ADDRESS (STREET OR R.F.O. HO.. CITY OR 311) <br />,, L. Olson -Wife -520 S. Broadwell -Grand Islas • <br />URI <br />SAL. Cremation. Rammed <br />se.. Burial <br />•' <br />June 15, 1987 <br />CEMETERY OR CREMATORY— NAME <br />Westlawn Memorial Park <br />LOCATION CITY OR TOWN STATE <br />sod. Grand Island NE. <br />nr.' jj Tr rd <br />t ' T1 ,l or^r r <br />• i <br />111.0. <br />F UNERAL HOME —NAME AND ADDRESS (STREET OR .0. NO.. CITY 02 TOWN. SIAM 2W) <br />• fel- Butler- Geddes 1123 W. 2nd, Grand Island, NE. 6880 <br />i • • ( I / �j <br />V + 17 <br />DATE SIGNED (Me. Day. Yr.) <br />74m <br />NOUR OF DEATH <br />24b. M <br />'• • (A1... ,.l <br />CO <br />27b- — —/ S ----4 F <br />"T : A 14 0 L <br />43c. / M <br />PRONOUNCED DEAD <br />(Mo., Day, Yr.) <br />24c. <br />PRONOUNCED DEAD (Ne.rl <br />244. <br />le lire bee M ea • <br />.e..el.l _.4. epee. Me see Mee y� IA.c. N <br />/// <br />sirww.. lltle) �► � L 6 <br />O M. b i demo <br />i iNNr. <br />wi. .f ...wi..N..vyr . .�y NMIion mowed et <br />M e K.Ie MN edr sl.c...d .d rw .. dM W • <br />Ia. <br />■ 24.. rlie.aw , ..d Title) <br />Ibibmmur <br />ADDRESS OF CEET (PHYSICIAN. C0710NE1CS IAN Oil AAT3RN €Y) (Type or Print) <br />Robert R. Roefoot M.D. 727 N. Custer, Grand Island, NE. 68801 <br />>t.. ► • <br />1 <br />DATE RECEIVED RY REGISTRAR (Me.. Der. Yr.) <br />24b. JUN 1 7 1987 <br />77 TE CAUSE (ENTER ONLY ON AWE PER UNE (o). (b), AND (c)) t.un& keM....en..d dee* <br />• <br />M ' <br />DUE TO. OR Al A CONSEQUENCE OF : <br />dNel belwe. ..... Mid 6110W W <br />PAR► MOM S10NIHCAe1T C NOHION! —Crd Lis.. ce...d:r <br />lb! Or dank d b nor rele.ed <br />N <br />. MALE W MIRE A <br />PART IM N FI <br />M lONANCY IN Mt PAST 3 MON1NiT <br />Y« O N. <br />AU T <br />(Spea ! <br />W <br />SLIMES <br />(Spec** Yews Net /� <br />ACCRO NC1 <br />MIT, f101. IWJasOSS. UNOI1. <br />OR 110111110 IMItS110ATION. neat /y) <br />DATE OF 1 1A et Me.. . 0.r. Tr./ <br />30b <br />HOUR Of Iw uRY <br />30c M <br />0(SCRNI 140W INJURY OCCURRID <br />304. <br />WWI AT WON <br />1Sp Ur er Net <br />HAT! O IIIJU�f :. Ar iiewe fs bO.q• <br />Olin Wheel" eke isome#►t <br />310. <br />LOCATION STREET OR R.F.O. No. CITY OR TOWN STARE <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENTTOF "HEALTN BIND <br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE QRi INt4C3f9Q . <br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES,, .VITAL. RECORDS, <br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. b t �� <br />DATE OF ISSUANCE <br />APR 2 9 2015 <br />LINCOLN, NEBRASKA <br />STATE OF NEBRASKA <br />201503325 <br />STATE OF NEBRASKA — DEPARTMENT OF HEALTH <br />SMEAR OF VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />STANLE OQE <br />A SIST ,Q I <br />' D?Q,ARTMENT OF HE <br /># HUMAN, RVICES <br />er „ <br />01700 <br />