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<br />RECORDER'S MEMO: The South Half (S%) of Lot Fourteen (14) and all of
<br />Lot Sixteen (16), in Block Eighteen (18) in Scarff's Addition to West
<br />Lawn in the City of Grand Island, Hall County, Nebraska.
<br />WHEN THIS COPYCARMS THE RAISED SEAL OF THE NEBRASKA HEALTH AND
<br />SYSTEII4 IT CERTF IES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REC
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTYf4
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _=
<br />DATE OF ISSUANCE
<br />OCT 2 5 1999
<br />LINCOLN, NEBRASKA
<br />HEALTH AND
<br />E3=P�
<br />IF RE61L4TL�i�R
<br />200uU1664
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />Bateau of Vital Statistics r ry n 07800
<br />CERTIFICATE OF DEATH. / ( "
<br />oeC[ASm —NAME .1. :. . IA•t
<br />cz;
<br />C') an
<br />t dames Brantley Beck
<br />, Male
<br />CD
<br />CD -!
<br />,.
<br />RACE wool". Neaso, wrtacAn NIetaim.
<br />AGE —usr
<br />me 1
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<br />TOWN. OR LOCATION OF DEATH
<br />y uj
<br />n
<br />. __ :. , -. . ... , _..._.
<br />s"cP• Yes OR NO
<br />I -
<br />>, Grand Island ,,:
<br />Yes
<br />,.. Lutheran Memorial Hospital
<br />U
<br />Cn
<br />MARRIED, NEVER MARRIED,
<br />SURVNNG SPOUSE too wilt, Gnt .A1D11N wAW 1
<br />coum OTT
<br />WIDOWED. DNORCED I sMtrr/
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<br />I1111.
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<br />Cn 3
<br />1E. Married
<br />�,
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<br />CO
<br />:CND OF RUSNESS OR INDUSTRY
<br />WOe{1PIG SIIt, Mw r RlnReo 1
<br />1:. 0 0 2 2
<br />Is. r
<br />1,. Tire Departwnt Store
<br />INslw Cm'.rm STREET AND NUMBER
<br />RESIDENCE —STATE
<br />COUNTY
<br />CITY, TOWN, OR LOCATION
<br />Neb.
<br />Z
<br />1,,. Grand Island
<br />...
<br />(COPY s a No 1
<br />fzs 2222 W. 17th
<br />o
<br />RECORDER'S MEMO: The South Half (S%) of Lot Fourteen (14) and all of
<br />Lot Sixteen (16), in Block Eighteen (18) in Scarff's Addition to West
<br />Lawn in the City of Grand Island, Hall County, Nebraska.
<br />WHEN THIS COPYCARMS THE RAISED SEAL OF THE NEBRASKA HEALTH AND
<br />SYSTEII4 IT CERTF IES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REC
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTYf4
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _=
<br />DATE OF ISSUANCE
<br />OCT 2 5 1999
<br />LINCOLN, NEBRASKA
<br />HEALTH AND
<br />E3=P�
<br />IF RE61L4TL�i�R
<br />200uU1664
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />Bateau of Vital Statistics r ry n 07800
<br />CERTIFICATE OF DEATH. / ( "
<br />oeC[ASm —NAME .1. :. . IA•t
<br />SEX
<br />DATE OF DEATK 1 roNIN. DAY, TIAR I
<br />t dames Brantley Beck
<br />, Male
<br />July 229 1977
<br />,.
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<br />AGE —usr
<br />me 1
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<br />YNlon 1
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<br />DATE OF IN"" I Now". wT,
<br />COUNTY Of DEATH
<br />DAs.
<br />rJub
<br />DAYS
<br />wows
<br />YIN
<br />SSC. I WKWT I 17"O'gi
<br />T.Ap1
<br />VUA I
<br />., White
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<br />18 1
<br />� . >, 915
<br />1��
<br />TIT.' Ha 1
<br />TOWN. OR LOCATION OF DEATH
<br />INslse Cm "On
<br />HOSPITAL OR OTHER N*TITUTION—NAMF tor Plot ON t o em. cpe $lost AND NYrRa I
<br />. __ :. , -. . ... , _..._.
<br />s"cP• Yes OR NO
<br />I -
<br />>, Grand Island ,,:
<br />Yes
<br />,.. Lutheran Memorial Hospital
<br />STATE OF BIRTH T r now we Y.S.A., PIAre
<br />CITIZIN OF WHAT COUNTRY
<br />MARRIED, NEVER MARRIED,
<br />SURVNNG SPOUSE too wilt, Gnt .A1D11N wAW 1
<br />coum OTT
<br />WIDOWED. DNORCED I sMtrr/
<br />-
<br />I1111.
<br />B. North Carolina
<br />?. II. S. A:
<br />1E. Married
<br />Ethel Meyer
<br />SOCIAL SECURITY NUMBER
<br />USUAL OCCUPATION Ic1vt KIND Or Araelt OONI OwnP17�AtOSt Or
<br />:CND OF RUSNESS OR INDUSTRY
<br />WOe{1PIG SIIt, Mw r RlnReo 1
<br />1:. 0 0 2 2
<br />Is. r
<br />1,. Tire Departwnt Store
<br />INslw Cm'.rm STREET AND NUMBER
<br />RESIDENCE —STATE
<br />COUNTY
<br />CITY, TOWN, OR LOCATION
<br />Neb.
<br />Hall
<br />1,,. Grand Island
<br />...
<br />(COPY s a No 1
<br />fzs 2222 W. 17th
<br />1/«:
<br />1e, 14@
<br />FATHER —NAME flow. swami MOTHER
<br />— MAIDEN NAME .upp/ LAST
<br />LIARS
<br />13D. Hans B@ok If1.
<br />�Pontt
<br />ftb Franks
<br />WAS DECEASED MR IN U.S. ARMED FORCES? INFORMANT— NAME — RELATIONSHIP — HARING ADDRESS ISTO11 on R.r.D. No , CAT. oR IowN, sere, erI
<br />a.. nno "'`"�"' `"'"''"' no d""'''""`.' „..Ethel BOOk- spouse -2222 W. 17th, Grand Island News 68801
<br />OF PART 1. DEATH WAS CAUSED BY: IENTER ONLY ONE CAUSE PER LINE FOR (o), ft AND sell
<br />• AIA
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<br />Re WIN" ON"? AND DAMN
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<br />. Or At • COASIGROINCI 00:
<br />CoNenlows. OP ANY, -
<br />WNKN OAve most 90 I's)
<br />STAIt is cAYS1 /.i, ew to. OR AS A CONs1GY.MCe of:
<br />SrwT/�0 tot YNetR-
<br />ITIN. CAPS. IASI
<br />(t)
<br />PART R. OTHER SIOWKAM CONDMOOM COHMTKWO CONTRIBUTING TO DEATH OUT NOT EILATID
<br />PART ID. M FEMME. WAS THEE! A
<br />ALIT Y
<br />K YES Went PINOINOS CON.
<br />TO CAUSE GNN M PAR ND)
<br />POIGNANCY Te THE PAST S
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<br />C•Yf
<br />_... _ .
<br />YES O HO Er
<br />©
<br />De•TN
<br />A
<br />ACCIDENT, SUICIDE, HOMICIDE, DATE OF INAMY i ronTN. DAT, we-* 1
<br />NOUN
<br />HOW INJURY OCCURRED I I-/t. N•T%m W 101W.Y IN ►Ail 1 N PART 11, IRr T R I
<br />OR UNDETERMINED 1 srtcwv I
<br />Im.
<br />24.
<br />iEI.
<br />INJURY AT WORK PLACE
<br />I $"Corr TeS oo NO / OPPKS
<br />OF INJURY AT NGr1, PAR., SHORT. PACTORT,
<br />OM., TIC. I SPICIn 1
<br />LOCATION I SPIRIT OR I.P.D. N.O., CITT M TOWN. SCAR I
<br />CERTIFICATION— rCWM MT TZAR roam DAY TIAR
<br />AM LAST SAW NR. /a "Ove ON
<br />1 00/000-No, view NN
<br />DEATH OCCUTD Al Mt ►uK1. ON M
<br />PPITSKIAN: TO
<br />1 ARe1/0t0 1N1 7 /mil 7 �/7 7
<br />_
<br />NpNM OAT RAR
<br />—'f
<br />7/ 2j
<br />ROOt A M.
<br />tNOw v DAM, AND, TO IAN NST
<br />or rw INOwtoo" DAM
<br />TAR. WCIAMO rRNo / �P' TIC. /
<br />}II. -
<br />TI/
<br />,1R M To TNI CA%PMCSI STATeD.
<br />CERTNICATION —MW EXAMINER 04 CORONER: oN T1N IASOS OR INN oloYR m
<br />m1 ..ct "NT WAS ►40I0O1/NCID DtAD
<br />IEwA W-1TON or M @DOT /OD Tole ow"SmAloom, IN W orIN1oN,
<br />MONTH DAY weAR "Cull
<br />DAMN OCCYRD.D ON eN DAM AND Does IO TIN CAIINRI SIARD.
<br />M.
<br />M
<br />CERTNKR —NAME IrT" M PDINN
<br />A qt pq t.
<br />A E SIGNED Iro«m, DAT, TIARI
<br />Robert R. Koefoot M. D.
<br />y
<br />TT..
<br />M.
<br />_ _
<br />MAKING ADDRESS— CERTTFIER SINIT oil ..P. . No. Con a STAR t,P
<br />727 Nos. Custer Island N2h, tfl.
<br />BURIAL. CREMATION. REMOVAL CEMETERY OR CREMATORY —NAME LOCATION CIn OR TowN Tl•R
<br />I SPICIT I
<br />TM. Burial mWestlawn Memorial Park Md. Grand Island Neb.
<br />A 0Pnomm DAY, WADI
<br />FUNERAL HOME —NAME AND ADDRESS I STRAIT M R.P.D. No.. CITY OR tow ". STAII. Sir)
<br />26 1
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<br />/ X94 A A>E,f�
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