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a.IM <br />W <br />C <br />Y D Z <br />M CA <br />N <br />Uri <br />LEGAL: Lot Two Hundred Six (206) , West Lawn Addition, in the City of Grand <br />Island, Hall County, Nebraska <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEA <br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGl <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE )G <br />JAN 2 9 2001 AS <br />LINCOLN, NEBRASKA ti 0 010 0 7 4 0 HEALTH AND <br />AKA Ml <br />p1� AMD ETAn OP LATIN MA1I� uaA. rw NrPr <br />and Island, Nebraska <br />A STISTRAR -= <br />STATE OF NE UMM — DOMTMff OF HEALTH O <br />BUREAU OF VITAL STATISTICS <br />cUMMATE OF DEATH <br />Li ari A`A`Tuhl EEyI s an a DEATH AAWWk AW rrrl <br />F 23 1991 <br />• an a EIRTIN AAMI[L aNr. rrah <br />ft "W December 9, 1915 <br />LAct TH <br />as Nr.Y. �... Nr.wtes ❑ Ow t!s[sltN <br />- - - -. kM 0 ow ON&"^ swr ~ &W AwMh <br />C�_ <br />OUNTY Oi DEATH <br />co <br />Yes <br />1%4:12M <br />- STAM <br />ft cou"" <br />to CIT1I. TOIMN ON LOCATION <br />N. sTRUT ANO NUIIEER A1IAIsIIM zpc"N wSIOE CRY <br />f <br />a <br />z <br />N <br />(MMR rO. Aernsw [Mr\ <br />11. M llEaY[II YKrt GrrAMIt ar..t <br />IIARIIIEOFIEYEII MARRED <br />lA MAAK OF SPOUSE if aft pw Maj.* Aww <br />Mt l <br />O Y <br />' <br />IK "ON Nib* &W of 8" ORM Oarq AOM 1aa SND OP SLgM16M NDINTRY i [nr.Tlpal ta.�.r. enAr Aaear s.e. me.Nn.� <br />flow"Itra , <br />� V <br />e Retail Jewel 12 <br />es rk <br />7c- <br />FOUR Few ypOLE MST 17 MOTHEI MAIDEN NAME MITT MIDDLE LAST <br />He Rohli Louise Paul man <br />j <br />O <br />O <br />y <br />daAltepLRlrn1A <br />z <br />aft CEM"M 00 CREMATORY - NAME <br />M LOCATION CITY OR TOWN STAn <br />D. i <br />i� <br />rri <br />CD <br />Grand Island, Nebraska <br />• •EMATun a LICENSE No �Y d <br />a FINERAI HOME - NAME AND ADDRESS ISTNEET OR RI D NO. CRY OR TOWN. STATE '68801 <br />T <br />M <br />t' <br />O <br />o <br />' rd c acres 5 mLnutes <br />r v <br />AS A OF Win" W~ arc aM Otlar <br />t <br />cn <br />c J <br />7 <br />Arterioscleroti-q- heart disease years <br />O <br />m <br />s <br />� <br />E penile dementia <br />-c <br />cn <br />r <br />O <br />. WOOL HOMICIDE. UNDiT. <br />DATE OF N.NP! #^ DW.. of <br />/10UR DP MaA.AV Sla. DESCRIBE HOW NAAM OCCURRED <br />DR PEIONO NMSTIOATgM 0000" <br />12M <br />LEGAL: Lot Two Hundred Six (206) , West Lawn Addition, in the City of Grand <br />Island, Hall County, Nebraska <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEA <br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGl <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE )G <br />JAN 2 9 2001 AS <br />LINCOLN, NEBRASKA ti 0 010 0 7 4 0 HEALTH AND <br />AKA Ml <br />p1� AMD ETAn OP LATIN MA1I� uaA. rw NrPr <br />and Island, Nebraska <br />A STISTRAR -= <br />STATE OF NE UMM — DOMTMff OF HEALTH O <br />BUREAU OF VITAL STATISTICS <br />cUMMATE OF DEATH <br />Li ari A`A`Tuhl EEyI s an a DEATH AAWWk AW rrrl <br />F 23 1991 <br />• an a EIRTIN AAMI[L aNr. rrah <br />ft "W December 9, 1915 <br />LAct TH <br />as Nr.Y. �... Nr.wtes ❑ Ow t!s[sltN <br />- - - -. kM 0 ow ON&"^ swr ~ &W AwMh <br />SG Cft. WM 00 LOCATIOM (Y DON a LYtS <br />OSM "V ULAN <br />OUNTY Oi DEATH <br />Sataaritan village - villa <br />Gr <br />Yes <br />1%4:12M <br />- STAM <br />ft cou"" <br />to CIT1I. TOIMN ON LOCATION <br />N. sTRUT ANO NUIIEER A1IAIsIIM zpc"N wSIOE CRY <br />fSPrI, TePM�I <br />Uml"Yes <br />(MMR rO. Aernsw [Mr\ <br />11. M llEaY[II YKrt GrrAMIt ar..t <br />IIARIIIEOFIEYEII MARRED <br />lA MAAK OF SPOUSE if aft pw Maj.* Aww <br />Mt l <br />O Y <br />11Z <br />WIOOwtD. OMORCED (ESMMNIT <br />IK "ON Nib* &W of 8" ORM Oarq AOM 1aa SND OP SLgM16M NDINTRY i [nr.Tlpal ta.�.r. enAr Aaear s.e. me.Nn.� <br />flow"Itra , <br />� V <br />e Retail Jewel 12 <br />es rk <br />7c- <br />FOUR Few ypOLE MST 17 MOTHEI MAIDEN NAME MITT MIDDLE LAST <br />He Rohli Louise Paul man <br />It E1161 N MID —111 1S <br />00001M ANT . NAME - MAIWNG AODRESS ISTRSEt AF D NO. CRY ON TOWK STATE Deml <br />fM[i M et woo 7B,aa room as do" a Awns► <br />Skirl Richards 2824 Northwest Ave.Grand Island,NB <br />daAltepLRlrn1A <br />Sm DATE <br />aft CEM"M 00 CREMATORY - NAME <br />M LOCATION CITY OR TOWN STAn <br />D. i <br />i� <br />Nov 27, 1991 <br />Westlawn memorial Park <br />Grand Island, Nebraska <br />• •EMATun a LICENSE No �Y d <br />a FINERAI HOME - NAME AND ADDRESS ISTNEET OR RI D NO. CRY OR TOWN. STATE '68801 <br />T <br />fel- Butler- Geddes, 1123 W. 2nd, Grand Island, NE <br />sammon CAW" AMTEN ONLY ONE CAUSE PEA LNE FOR 1N. fet AND" wlaw bl"em ~ w "No <br />' rd c acres 5 mLnutes <br />AS A OF Win" W~ arc aM Otlar <br />t <br />ardial infarction :30 minutes <br />DUE T4 A CONOfOU6NCE Of: _ - + YAai.al boom" "M NO MAN <br />Arterioscleroti-q- heart disease years <br />SKOMMANT eON0R10M1- Calrwr cW**Wq b opm ete AM NMNC <br />PARE <br />PMT ■ i FEMALE WAS THERE A <br />PREGNANCY N THE PAST S MJMTMS? <br />26 AUTOPSY H WAS CASE REFERRED 70 MEDICAL <br />Apec,, YIN a AW EXAMNEA DR CORONER, <br />E penile dementia <br />Yes O No ❑ <br />no sI or NN <br />. WOOL HOMICIDE. UNDiT. <br />DATE OF N.NP! #^ DW.. of <br />/10UR DP MaA.AV Sla. DESCRIBE HOW NAAM OCCURRED <br />DR PEIONO NMSTIOATgM 0000" <br />12M <br />12ft <br />U& /6AIRY AT WORM 1N PLACE OF NAA\Y . Al Moll,. bet 1Maat Meal. <br />2ft LOCATION STREET OR RF.D. NO CRY OR TOWN STATE <br />1fP,a1 Yw s ANN emat AaMnS aM. <br />17r DATE OF DEATH pr. DaK nl Ma. DATE SIGNED Ar. Day. Y,.1 1116. TIME Of DEATH <br />November 23, 1991 <br />a <br />1R DATE SKMMED (ft. Dry. Yi) 1oe. TM E OP DEATH 1so. PRONOUNCED DEAD AM- Osy IT.! ISM PRONOUNCED DEAD (Mato <br />' <br />November 25 1991 12.00 A.M. M <br />F. <br />E Dow* err a [wry W d" ft C&AW t n Ary aawA asap au+r+a r <br />170. To b ear a Ary aeo.Iaspa oauew rSu re[ pus ry1 <br />d awIN /11Y1 a [v Nn[. OIIS aN OMe[ an0 M to b crrNH aw0. <br />(f� /� <br />aI10 E w T <br />f11a MO TOSAGM USE CONTIINITE TO THE DEATHT XL MAS ORGAN OR TISSUE DONATION SEEM CONSWEREGT . 106 WAS CONSENT GRANTED? <br />a YES ENO O UNKNOWN G YES 70 ND 0 YES O NO <br />AMD OP CUM" IPHYSICAK CORONERS PHVWM/ ORGOLWTV ATTORNEYI (4W ar P^M <br />-: er_ .nale L1Nitzel 31thtw1d Baltimore, Hastings, Nebraska 68901 <br />