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rn W <br />�•+� <br />t/ l l 8 4 4 <br />T D c� <br />� n z. <br />� � O <br />v� <br />c� <br />M ` —p <br />M <br />0 <br />rn <br />J <br />1� <br />WHEN THIS COPY CARRFES THE RAISED SEAL OF THE NEBRASKA HEALTH ANDS <br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE_ MI PbN: <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISVft- TTi@1f <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS G� <br />ATE OF ISSUANCE <br />JUN 15 1999 ASSisO&STATERI <br />LINCOLN, NEBRASKA HEALTH AND HUMAN SEMI9CE <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SE1t WEX,F O� <br />VITAL STATIST[cS <br />CERTIFICATE OF DEATH <br />iNT - NAME FIRST MIDDLE LAST 2. SEX 3. <br />C') (f) <br />o --j <br />�n <br />—i M <br />� o <br />rr; <br />M <br />r z <br />r n <br />x <br />n <br />MAR <br />99TEII <br />D SUPfbRT <br />CD <br />N <br />O <br />CD <br />CZ <br />CD <br />CD <br />ca <br />Nn <br />1 <br />Evelyn Helen <br />Niemann <br />Female May 19, 1999 <br />Ysar/ <br />�. CITY AND STATE OF BIRTH /M not in USA. name edvnayl <br />Sa. AGE -Last BirMday AR UNDER t DAV 6. DATE OF BIRTH /MOrWt. Dey. <br />(Yrs.l 77 SI <br />AYS 5c. HOURS' MINS. June 28, 1921 <br />O <br />Grand Island, Nebraska <br />7. SOCIAL SECURTIV NUMBER <br />Ba. PLACE OF DEATH <br />HOSPITAL: I_TAL: <br />Inpatient OTHER. ® Nursing Home <br />506 -09 -4883 <br />El ER Outpatient Residence <br />Bb. FACILITY - Name l// not mshadtion, give slroel and number) <br />ElDOA El Other /SpecrM <br />Park Place Nursing Center <br />Bc. CITY. TOWN OR LOCATION OF DEATH <br />Bd. INSIDE CITY LIMITS <br />Be COUNTY OF DEATH <br />Yes ® No <br />Hall <br />xj <br />Grand Island <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (Including Zp Cade! 9e INSIDE CITY LIMITS <br />9a. RESIDENCE -STATE 9b. COUNTY <br />Grand Island <br />516 N. Grace St. 68803 Y °° ® "° <br />rt7 <br />Nebraska Hall <br />American Indian. 11. ANCESTRY 1e.9- hfdlah• Mexican. German, etc) 12. Li """ED ®WIDOWED 13. NAME OF SPOUSE le wile. give maiden name) <br />x <br />10. RACE - (eg., White. Black. <br />etc.) lSpewM (Specify) <br />White German <br />NEVER DIVORCED <br />t <a. USUAL OCCUPATION /Give kindolwwk done dudlg masl lab. KING OF BUSINESS INDUSTRY <br />15. EDUCATION (Spetiy Dory hgMSt prWe comPtetedl <br />EbmentarYyor Seeondar,1L710 -t21 Coaege 11 -aa5•I <br />• <br />of working Ida, even il,el,;edl <br />Forklift <br />Government <br />12 tl 1 Grace <br />MAIDEN SURNAME <br />16. FATHER -NAME FIRST MIDDLE <br />LAST 17. MOTHER <br />FIRST MIDDLE <br />H NMI Rickert <br />Anna NMI Sieman <br />1B. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT -NAME <br />(Yea no or unk.) IN yes. give war and dates of services) <br />Luth <br />140 .11 �r .nnraccc ISTREET OR R.F.D. NO., <br />Sharon <br />CITY OR TOWN. STATE, ZIP) <br />II v <br />f <br />1 "IN <br />si <br />/a __ I f— A I I <br />ru <br />C <br />fn j <br />.it.ti T Vn l.nmnvr - - <br />Grand Island, Nebraska <br />c run im. lol. nnu wn <br />/^ A _. — _ — <br />�Gi� L��J•tI ��� /1t�f�1 <br />balteaan 011N1 and asatn <br />between onset and deem <br />EXAMINER OR CORONER? <br />28e. On the basis of examination and,or Investigation, in my opinion aeam occune° ar <br />Me time. date and pace and due to OW causes) stated. <br />