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Garold <br />Abaft CWA MC <br />rit 15, 1994 <br />Ginn., Nebraska <br />' 70 <br />.. 31, 1923 <br />506 20 4721 <br />• MAW <br />HOONML. ❑ — me ❑ «..■ <br />❑ IN Oaf.. li <br />1 ❑ DOA ❑ <br />'l.■. Mfaaa.R.YA PpaO.LA..■aniq <br />ease: 2330 N. Koenig <br />- , <br />... <br />G end Island <br />w <br />- , UNITS <br />Y.. CI N. ❑ <br />k • • • OF DEATH <br />Hall <br />- - .1M <br />1rwli..IRA <br />mita I <br />11. �J.. R ;. <br />Am. American <br />hand <br />Island <br />.R) 12 MAow° <br />0 0 r1.N;;� , <br />25 <br />LAs <br />n <br />M. ' 0 <br />■.wAr■y <br />+ttlMM4.ma a..••A•41•hrr <br />Comer • • : - for 'e 3 <br />Mk MOOR MOMS INDUSTRY <br />Li . • Store <br />1,S° <br />17 . MOTHER MST <br />Zella <br />W. <br />`'' " " <br />'^^' <br />e1 - <br />Yee. 9= 10-46 <br />lie NPOIMWR -NAME <br />Margaret Bellaire <br />14 NFOIBMNT warm manse STREET OR ALPO. <br />2520 W. wig, Grand Island, <br />NO. CITY OR TOWN STATE. OW <br />NE. 68803 <br />20 agrum- BSUTUREounitlE 140 T yl , / j <br />� A _. ®. _'~!7a• <br />i -- - ' HONE• <br />Apfel- Butler - Geddes Funeral ::.., <br />— <br />2la IEINODO, ONPOBRION <br />■ I <br />2* DATE <br />May 18, 199 <br />�1 <br />g rf <br />_ II ONAINA 0Oman <br />214. CEMETERY cneutonv Lamm <br />Grand eland, ME <br />226 P MP. NOW ACORr86 (STREET CRRFD. NO. CTI ORTOLAN, <br />1123 West Second, Grand Is] NE. 68801 <br />23. M■d®MTE WM COMM ONLY ;MUSE PERLNE FOR lM RI. M OAB <br />' NN <br />01010.0RASA r. -:.v. - • <br />0) <br />DINE TO. OR AS A OONISEOUENCE OF <br />02 <br />P OTHER SIGNIFICANT COMMONS • Can /biN e4aRt'6ng brie wain ON nal Mow <br />■ <br />PART 01 RIME ME. WAS TAME A <br />PREGNANCY N THE PAS <br />(*8..'0443 Ye 1 1 ND <br />24 AUTOPSY <br />YN L I .H <br />I''7 <br />2 •• <br />❑ AS»❑ Undeimined <br />In &M•S ❑ PonOiq <br />NI <br />210. DATE °M OW ma. Dot W <br />20 NOM OF N■ATY <br />hi <br />205 DESCRIBE NOW INJURY I <br />lA <br />20a WPM AT WORK 2.L P� y -AllplAaynt 'VW *On <br />MC ISpIL7M <br />Yet ❑ Na • <br />24g LOCATION STREET OR RPM N0. <br />-. <br />M ea <br />�Mrewo, <br />Aoo lcos £ <br />27a DATE OF DEATH Mb. AM WJ <br />5 tS - 1 , t <br />24a DATE 81f4NE0 Alb. qy. n./ <br />270 DATE ammo 1M. AI,, n) <br />i <br />270. To <br />27e THE • <br />010 <br />moucuton <br />3001d SUM <br />IAN <br />we PRONOUNCED DEAD Alfa OIX NJ <br />SA WO al mist <br />' mufti <br />BIllwa. sad TIM► <br />We On Ss OW.dw.n...plriql <br />.N lima . die .II■Fl.e..N A.bri. e.Y.lNI <br />' <br />er w fOEACCO USE CONTRIBUTE 713 THE DEATH? S■. HAS ORGAN OR TISSUE DONATION OONEDe1E0? <br />II YES NO 0 •-.. 0 148 NO <br />— -- <br />33. <br />30D WAS � • •" - <br />L■YM TEM <br />1 188 w <br />NAME MID ADDRESS OF CERTIFIER R KBWROIERS :. OR COUNTY ATTORNEYS IrM.arPylry <br />J.J. Cannel a M.D. 729 N. Custer, Grand Island, NE. • : :83 <br />_ <br />32.. REGISTRAR _ 7 220. DATE FILED BY " < ..: <br />- AMA. Op AAJ <br />1 <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPART <br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF Pitt <br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SE %I'E <br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. •' <br />DATE OF ISSUANCE <br />JUL 2 2 2015 <br />LINCOLN, NEBRASKA <br />STATE OF NEBRASKA <br />201505412 <br />