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rn r) v) <br />M <br />M <br />V1 <br />0 <br />WHEN THIS COPY CARRIES ThE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REPDRD­ONPLE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA TfSqWMt-ff0X,-iw=t(!S <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />ORE <br />200001375 <br />FEB 16 2000 AM: -.T. 9:1P <br />SSA- N-T&?ATt9Mft t0jC <br />LINCOLN, NEBRASKA HEALTH AND IAN&N SERVICES SY.M9 <br />SrATROF NEBRASKA- DEPARDWff OF BMTH AMMMAN MKVXES MCA= AWDStWP01M;- <br />VfTALSTATNM <br />CLRTMrATP nV nVATU Qq 1 nQ72 <br />1. O@CftftT-k*A* FIRST Mow LAST <br />a SEX <br />'I DATE 0 <br />'I DATE OF MATH Atm Qw. rw <br />C> to <br />C3 <br />rel. <br />4WVANOSTAT10FOMM ffWnU1AAmm <br />A <br />" "w "'O'e. <br />ft AGE -UN <br />UNDERIVEAR <br />-wy-$ <br />ca <br />-To wff" Aftm fw y6j" <br />W 1 <br />I ! <br />S& HOUN Lfts <br />�S <br />,Grand Island, Nebraska <br />[-W7 <br />ff-92 �- <br />February 28, 1916 <br />kwom SECUIM 111"!MKR <br />w� <br />ft PLACE OF MATH. <br />0 <br />—307-76-6079 <br />76- <br />O'NER, ❑ *—q- <br />❑ EA 0AW"M Awft <br />cm <br />St. r <br />St. Francis Medical Center <br />cm <br />AIL WV1 TOM ON LOCATION OF MATH <br />rTT <br />COUNTY OF RUTH <br />'*Hall <br />Grand Island —I" <br />—< <:> <br />I <br />CcD .. <br />a COUNTV <br />ft CITY. TOM ON LOCATION <br />ft PAWAMMAIM oft" 03 <br />C> <br />C:D <br />a> <br />C> <br />6238 N. North Road <br />Y. L] 'a <br />• Wo. VAft buk A~00 VdM 11. ANMTRY 166- NOW MuCaft OVOW M 10 1 a] MARAW OWWM 0060winaftoww <br />. 09 RACE 13 ww OF SPOM <br />C:) <br />w <br />I" WiftoccuPATON ft KINDOFoUSINESSINDUSTAV It EDUCATION ft!!t <br />of -ft~fM"* q10 <br />*14 C~ 114 W S" <br />Nomemaker I'Domeatic <br />19 FATHER -NAME FIRST mom LAST 17 <br />M <br />CD <br />w <br />rn <br />r-1 <br />EVER Of UAL ARMED FORCES? <br />ift INFOOMONT - VAR <br />r <br />F--A <br />I <br />U) <br />1 -- — <br />Earl Pollock <br />co <br />w <br />n rp"Alm-ow"Tuas UCOM NO <br />21► METHOD OF 04P( WON <br />2,G DATt 21C <br />C.0 <br />;K <br />CD <br />Westlawn Memorial Park <br />as PUMENIAL Noma • NAME <br />r10 <br />3> <br />C] El <br />CD <br />= PUNWAL NOW ADDRESS AWREFT 09 FLF 0 NO CITY OR TOWN STATE ZIM <br />601 North Webb Road, Grand Island Nebraska 68803 <br />As Aw ■IMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER UNE FOR ta IM AND lc# <br />Acute intracerebral bleed <br />A <br />DUE TQ OR AS A CONSEOUENCE OF Wawvo Demo" wNar ww deav <br />DUE TO. OR AS A CONSEOUENCE OF <br />WHEN THIS COPY CARRIES ThE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REPDRD­ONPLE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA TfSqWMt-ff0X,-iw=t(!S <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />ORE <br />200001375 <br />FEB 16 2000 AM: -.T. 9:1P <br />SSA- N-T&?ATt9Mft t0jC <br />LINCOLN, NEBRASKA HEALTH AND IAN&N SERVICES SY.M9 <br />SrATROF NEBRASKA- DEPARDWff OF BMTH AMMMAN MKVXES MCA= AWDStWP01M;- <br />VfTALSTATNM <br />CLRTMrATP nV nVATU Qq 1 nQ72 <br />1. O@CftftT-k*A* FIRST Mow LAST <br />a SEX <br />'I DATE 0 <br />'I DATE OF MATH Atm Qw. rw <br />Anna Irene Pollock <br />Female <br />�eAS <br />September <br />September 26, 1998 <br />4WVANOSTAT10FOMM ffWnU1AAmm <br />A <br />" "w "'O'e. <br />ft AGE -UN <br />UNDERIVEAR <br />-wy-$ <br />UNOERI DAY <br />-To wff" Aftm fw y6j" <br />W 1 <br />I ! <br />S& HOUN Lfts <br />�S <br />,Grand Island, Nebraska <br />[-W7 <br />ff-92 �- <br />February 28, 1916 <br />kwom SECUIM 111"!MKR <br />w� <br />ft PLACE OF MATH. <br />0 <br />—307-76-6079 <br />76- <br />O'NER, ❑ *—q- <br />❑ EA 0AW"M Awft <br />St. r <br />St. Francis Medical Center <br />❑ WA ❑ Ovw AMC*, <br />AIL WV1 TOM ON LOCATION OF MATH <br />""-MIKYL73 <br />COUNTY OF RUTH <br />'*Hall <br />Grand Island —I" <br />I <br />V& IUKWWX -STATE <br />a COUNTV <br />ft CITY. TOM ON LOCATION <br />ft PAWAMMAIM oft" 03 <br />ftoodm"C" <br />Nebraska <br />Hall <br />Grand Island <br />6238 N. North Road <br />Y. L] 'a <br />• Wo. VAft buk A~00 VdM 11. ANMTRY 166- NOW MuCaft OVOW M 10 1 a] MARAW OWWM 0060winaftoww <br />. 09 RACE 13 ww OF SPOM <br />■usswem I NrM <br />White German <br />1 <br />EIUA� Earl Pollock <br />I" WiftoccuPATON ft KINDOFoUSINESSINDUSTAV It EDUCATION ft!!t <br />of -ft~fM"* q10 <br />*14 C~ 114 W S" <br />Nomemaker I'Domeatic <br />19 FATHER -NAME FIRST mom LAST 17 <br />MOTHER MKIOLI MAMEN <br />John. Henry Meier <br />Anna Irene Lohmann <br />19 WAS DECEASED <br />EVER Of UAL ARMED FORCES? <br />ift INFOOMONT - VAR <br />lym Re or WN <br />0 Im 9" ow wd dms d swoftd <br />I <br />No <br />1 -- — <br />Earl Pollock <br />oft ■0N)11IMINT MAOUNOADORISS ISTREST OR RP D NO. CITY 001 TOWN. PATE. ZM <br />6238 N. North Road. Grand Island Nebraska 68803 <br />n rp"Alm-ow"Tuas UCOM NO <br />21► METHOD OF 04P( WON <br />2,G DATt 21C <br />CAMETIMORCAEMATOOW NAME <br />A. QA, &*CA;L* // 43 <br />Sept. 30 lQQA <br />Westlawn Memorial Park <br />as PUMENIAL Noma • NAME <br />219 CEMETERY ORCAEMATOM OR TOM PATE <br />Livingston-Sondermann <br />C] El <br />- Grand Island, Nebraska <br />= PUNWAL NOW ADDRESS AWREFT 09 FLF 0 NO CITY OR TOWN STATE ZIM <br />601 North Webb Road, Grand Island Nebraska 68803 <br />As Aw ■IMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER UNE FOR ta IM AND lc# <br />Acute intracerebral bleed <br />A <br />DUE TQ OR AS A CONSEOUENCE OF Wawvo Demo" wNar ww deav <br />DUE TO. OR AS A CONSEOUENCE OF <br />OTHER SKWdF1CANT CONOMONS - CAmPh" CW*OuWV to Na abdA tkd no WANG PART <br />PART <br />0 OF FEMALE WAS THERE A 24". <br />AUTOPSY. <br />21. AS CASE REFERRED TO MEDICAL <br />PREONANCY <br />■ <br />IN THE PAST 3 MONTHP <br />1 <br />A <br />EXAMINER OR CORONEOP <br />ft- 10-541 y" n - F1 <br />0 40 <br />YM No <br />as <br />3ft DATE OF ftAO" Aft Der Yl <br />2.e HOUR OF ftJURY <br />HOW ftJURVOCCUW" <br />0-0 <br />1 <br />j2ft0ESCR10E <br />M <br />OS.00 0 Paaprq <br />29* PCIUMV AT WORK <br />mm <br />=L2:4A@XM %CIXY <br />24 LOCATIO- STREET ORR F 0 NO CftV OR TOWN STATE <br />❑ Ito "w"Oppoft <br />Yn Ej N. [—] <br />120 <br />27& DATE OF DEATH AM OAV "1 <br />28@ DATE SIONED jW Oo, w, <br />200 TAW OF MATH <br />dSEPTEHBER 26, 1998 <br />!" <br />'SKO" " OAY Y, I <br />VC TIME OF DEATH <br />A <br />Me PAONOuCE0 DEAD ise o& wi <br />2ft PRONOUNCED DEAD w <br />October I O98 <br />10:40A m <br />M <br />j <br />jig <br />270 <br />2% 0, we bfte ce ow"-s". &W w w-vagowk . Nq opc. ow am~ a <br />PO W". dft AM PIKO Ww *A 0 " ca"" Now <br />fsw�lft" Wd TOM b <br />n 00 TOBACCO <br />USE CONTF0 30a <br />,�9540 TK DEATH? <br />❑ El ❑ <br />HAS ORGAN OR TISSUE DONATION KEN 904*OEAEDI 300 <br />3-C <br />WAS CONUNT GAANTFOI <br />YES NO <br />❑ YES Gy-O <br />YES Eie" <br />31 WAIR AND ADDRESS OF CERTIFOR 1PHYS110AN. CORONER S P"VIOAN OR COUNTY ATTOANEVI 1TWOO'p-0 <br />9 WILLIAM J LAWTON MD 2444 W FAIDLEY GRAND ISLAND NE 68803 <br />Ift RE&STRAR <br />AQ ic <br />3 a DATE ruo ev N"T TA" Aft Oft "A <br />I OC <br />zj�n= <br />7 rm- <br />�'4\ <br />zlt <br />LEGAL: LOT 1 BIRTWELL SECOND SUBDIVISION, HALL COUNTY, NEBRASKA, EXCEPTING <br />