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7, SOCCIA W NUMBER <br />507 -22 -4492 <br />9. PLACE OF DEATH <br />sOSPIT AL <br />INSIDE Cm LINTS <br />Yw ®Ne Q <br />❑ .nuns <br />OT kJ Nuerg •ease <br />GIOMea Rndrre <br />❑ ........... <br />OF DEATH <br />Hatt <br />11. ,9 <br />B. FACIITY <br />t. <br />- NMI. IM Me osAlbi 0.4 seer MO •AAIaa'J <br />Francis Skilled Ca rte <br />OR LOCATION OF DEATH I9. <br />Island <br />ill uGa <br />ee courav <br />Et CITY. TOWN <br />and <br />9. RESIDENCE- STATE i 9 COUNTY <br />aska I H2 <br />/O. RAGE - le. WA.e. Black Amnon Mat <br />MO <br />G1" White <br />I4 USUAL OCCUPATION /GAT UdPlmnl obleaM.gmog <br />of .a.ey WA OwnIIe1lle0 <br />Fanmi r g <br />11. ANCESTRY le9 1WM. <br />American <br />Meocan.eemw. <br />1m <br />CITY. TON* OR LOCATION <br />9c CITY. <br />Cean4 Tq1 a <br />00 <br />KINO OF BUSINESS INDUSTRY <br />7�L2ri Hen t <br />LJL7' <br />+2 5] MARRIE?MOWED MAED <br />L <br />q D <br />Al STAB' ET AFY)NUIEER <br />Am w <br />a ?OWED <br />QOR`� <br />i IS EDUCATION. <br />~ Eiane.19 <br />1 8th <br />FgST <br />Marie <br />) 9e .�DEarrurrs <br />eh2c* Ze Coati El <br />R4• I vs w <br />13 NAME OF SPOUSE u .t 9e* eraee.rlP/ <br />rt $ <br />#* Ca jgM <br />1 ■ W <br />1T ?A OT1*R <br />v O: SecoNlary OM C00100 !1 - *.y 5 - 1 <br />Y MAIDEN SURNAME <br />Baden <br />16 FATHER -NAME FRST <br />l6 WAS DECEASED EVER IN U.S ARMED FORCES? <br />Mato. of ∎HILT laves 9•• ewe Me ales <br />NO I <br />PI law Call <br />ISTREET OR RFO <br />e.e e • <br />9,3 , <br />/ 4 Q Y <br />, 19A INFORMANT <br />i <br />NO CITY Gal <br />-,r• _ _ <br />a --:. • <br />( [ Bra <br />-11AME <br />7 �yyy�Q _ <br />TOYW ital n'1 <br />AML INF MAIMS ADOIESS <br />/CA.:- : e <br />�• SIGNATURE 6 L NO <br />■ • .... <br />❑ RMMVa <br />D Drat, <br />T • O DATE 121.:. CEMETERY ORCREMATOFV NAIE <br />October 12, 00 Westlawn Memorial Park <br />• . NAeIE <br />; • fe].- Butler- Geddes <br />OR RF.D 1 40. CITY OR TOWN. <br />Grand Island, <br />1 219 CEMETTdRY OR CREMATORY IODATION OTT OR TOWN STATE <br />1 Grand Island, Nebras - <br />_ ..." <br />68801 <br />ill °i"'°" <br />22E FUNERAL IONE ADDRESS ISTREET <br />1123 West Second <br />STATE, 2'o1 <br />Nebraska <br />YEDMTE CAUSE TENTER ONLY ONE CAUSE PER LINE FOR ., M. RHO .01 - - PORT* WARP. maxi a-V Orr <br />P, I P Meatastatic small cell carcinoma of the lung. <br />JUE .. A OR AS A CONSEOUEHCE OF Very& ' ' ° ' ' HIA ard. <br />Cw <br />DUE TO OR AS A CONSEOUENCE OF Pap. '•a••r' vA* a•.2 P.M <br />KJ <br />_ � OTT , HE E� R SIDNi1CAMTT cC9N canes.: co•IOWI6 Own to pp WOW <br />\h on c obstructive pulmonary disease <br />I PART AI 19 FEMALE WAS THERE A 24 AUTOPSY <br />jL" <br />! V I M TYEM No MONTHS, ,es ❑ <br />11 iAew <br />25 WAj :25E G T.., REDKM <br />E><AAw CORORe / <br />Y�JI� <br />269 <br />L7 AeatlM <br />0 Sawa* <br />HaNpee <br />((''�' 12ee DATE OF rLAM 5 A Ib aw Yrl i 28c HOUR OF INAPT - 26a. DESCRIBE HOW ../CRY 0CCuRRED <br />e...i on...—we I M <br />990 NO i •TY OR TOr ATE <br />0 Penang , 26a INJURY AT WOAI j 2M �IN11.r le SP egme 9. wee Hwy 26s LOCATION STREET 09 w ST <br />f •k eeiYl .. <br />1••.e•9eb•• Yes 0 ...D .. <br />S 1 <br />t <br />1 <br />27a DATE OF DEATH AAt Day w; 2* GATE SIGNED NU J.. r, I -e TIME OF DEATH <br />10 -07 -2000 w <br />D 290 aDNOU, * F -• `DEAD Etta. <br />M 15. ; 272 TI Lge E OF DEATH 262 PPO NCED DEAD it M Y. P <br />I 10 -10 -2000 16:53 M w <br />3 <br />273 To WOWS al mY v ale dlNe and and due 1 Ye E <br />0*99 1(11110 ' <br />{ ■•e f reRt L t <br />2991 Or re Wen et a•ammalt , er.e a Y..INP9oeen "i A WPM' .Ores Je:2N7e r <br />Re -* OM aMmacs 4Te0 gee C*RMS: WOW <br />, ScRO <br />:'.ONSDERE 7' ' 30 o *AS CONSENT GRANTED'. <br />�K, El TES <br />29 OD TCIIE <br />CONTRIBUTE 70 071TFn <br />❑ UNKNOWN <br />A HAS ORGAN OR T55+..E p 7109 6E£N <br />❑ TES <br />fi YES II NO <br />31 NAME AND ADDRESS OF LER16Q1 r99YSICIAN. <br />William J Lawton <br />CORONERS PHV9ICMN OR COUNTY ATTORNE• 'ear* P• +T. <br />MD 2444 j. Faidlpy, Grand Island, NE 68803 <br />DATE OF ISSUANCE <br />MAY 19 2015 <br />LINCOLN, NEBRASKA <br />[324 REC-•STRAR <br />STATE OF NEBRASKA <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND <br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORICNIA172tCORD ON <br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS <br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />201.;)03895 <br />STANLEY DOPER <br />A$'SISTAIT TAT RE GISTRAR <br />pEPARDWOi : <br />HUNAN ; *Elva <br />STATE OE NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERMON E <br />VITAL STATE <br />CERTIFICATE OF DEATH <br />I t OECEDEar -maw FIRST SOME UST 12 SEX 7 3 OA9E -F44AT9 mom aw rico . -; <br />Arnold Wilhelm pbs male tuber 7 2DOD <br />C T ( APOSTATE OF B I R T H Oman L nanr cavalry, ; Sa AGE Lame SrOa 1 UNDER 1 YEAR UNDER t DA•' • 6 !ATE HP EXPTH 944,08 Ae. rwlel <br />IYn <br />>';Avs ' i. .z J9s tams 1 <br />329 DATE FIED 'MAP 1 • <br />QCT 2 0 <br />