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<br />Lot Eight (8) in Block Five
<br />Addition to the City of
<br />Nebraska
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE.A,,TRUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE.DEVARTNENT'OF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAI DEPOSZTO'RY.FOR
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE ,(
<br />JUL 2 0 W7 STANL ` ,' DIRECTOR
<br />LINCOLN, NEBRASKA BUREAU �F ,VAS <; STATISTICS
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
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<br />DECEDENT -NAME FIRST MIDDLE LAST
<br />SEX
<br />DATE Of DEATH (Mo., Day, Yr.)
<br />1. LUCILE ETTA BROWN
<br />1,. Female
<br />13, July 8, 1987
<br />F -►
<br />CD Cn
<br />-Loo Bi.%doy
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />DATE OF BIRTH (Mo., Day, Yr.)
<br />DAYS
<br />HOURS MINS.
<br />Indian, ek.)(Spocify)
<br />Garman, k.) (Specify)
<br />White
<br />American
<br />66
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<br />ame country)
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<br />WIDOWED, DIVORCED (Specify)
<br />Co Z,,I
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<br />Pawnee City, Nebraska
<br />v U.S.A.
<br />10. Married
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<br />Of 6USINESS OR INDUSTRr
<br />COUNTY Of DEATH
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<br />2505 -26 -6999
<br />13o. Saes Clerk )3b.
<br />Store
<br />14o. Hall
<br />ITY, TOWN OR LOCATION OF DEATH
<br />INSIDE CITY LIMITS
<br />HOSPITAL OR OTHER INSTITUTION - Nome (If not in either, IF
<br />NOS►. OR INST, IndiceN DOA,
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<br />(Sp*cif�� ec or No)
<br />Yes
<br />give HnN and number( Ouryoti—
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<br />14d.930 Vine St. 14..
<br />AT. HOME
<br />RESIDENCE - STATE
<br />Cn
<br />(5) in
<br />Clau -ssen
<br />Country
<br />view
<br />Grand
<br />Island,
<br />Hall
<br />County,
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE.A,,TRUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE.DEVARTNENT'OF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAI DEPOSZTO'RY.FOR
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE ,(
<br />JUL 2 0 W7 STANL ` ,' DIRECTOR
<br />LINCOLN, NEBRASKA BUREAU �F ,VAS <; STATISTICS
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
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<br />DECEDENT -NAME FIRST MIDDLE LAST
<br />SEX
<br />DATE Of DEATH (Mo., Day, Yr.)
<br />1. LUCILE ETTA BROWN
<br />1,. Female
<br />13, July 8, 1987
<br />RACE - (e.p., White, Black, American
<br />ORIGIN /DESCENT (e.g., Italian, Mexico., AGE
<br />-Loo Bi.%doy
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />DATE OF BIRTH (Mo., Day, Yr.)
<br />DAYS
<br />HOURS MINS.
<br />Indian, ek.)(Spocify)
<br />Garman, k.) (Specify)
<br />White
<br />American
<br />66
<br />26, 1920
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<br />:. 60.
<br />6a
<br />b.
<br />IS a<.
<br />7.July
<br />ITY AND STATE OF BIRTH (N net in U.S.A.,
<br />CITIZEN OF WHAT COUNTRY
<br />MARRIED, NEVER MARRIED,
<br />NAME OF SPOUSE (If vvife, give maid*. name)
<br />ame country)
<br />WIDOWED, DIVORCED (Specify)
<br />Pawnee City, Nebraska
<br />v U.S.A.
<br />10. Married
<br />,,.Russel R. Brown
<br />OCIAI SECURITY NUMBER
<br />I
<br />USUAL C1CCU►ATION (Give kind el work don* during molt KING
<br />Of 6USINESS OR INDUSTRr
<br />COUNTY Of DEATH
<br />of working life, even if retired
<br />Sears De t .
<br />P
<br />2505 -26 -6999
<br />13o. Saes Clerk )3b.
<br />Store
<br />14o. Hall
<br />ITY, TOWN OR LOCATION OF DEATH
<br />INSIDE CITY LIMITS
<br />HOSPITAL OR OTHER INSTITUTION - Nome (If not in either, IF
<br />NOS►. OR INST, IndiceN DOA,
<br />Grand Island, Nebraska,k
<br />(Sp*cif�� ec or No)
<br />Yes
<br />give HnN and number( Ouryoti—
<br />S.
<br />f /f-s.. R., Inpoti—I (Sp«ify)
<br />14b.
<br />14d.930 Vine St. 14..
<br />AT. HOME
<br />RESIDENCE - STATE
<br />COUNTY
<br />CITY, TOWN OR LOCATION
<br />STREET AND NUMBER
<br />INSIDE CITY LIMITS
<br />,:,.Nebraska
<br />1 :b. Hall
<br />,RGrand Island
<br />I:d.930 S. Vine St.
<br />(Specify Yes or No)
<br />,sxes
<br />FATHER -NAME FIRST MIDDLE LAST
<br />MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />Guy NMI Stone
<br />1 Gladys NMI Perdew
<br />,.
<br />17.
<br />WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />INFORMANT- NAME - RELATIONSHIP - MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP)
<br />(Yet, no, e. unk) (II yet, givo rev on dare. of .erv:n)
<br />,B. Yes 12 -29-43 1 -8 -45
<br />1}OVi
<br />igRussel R.Brown- Husband -930 S.Vine• Grand Island, e.
<br />BURIAL, Cremation, Remova]2ob.July
<br />DATE
<br />CEMETERY OR CREMATORY -NAME
<br />LOCATION CITY OR TOWN STATE
<br />20, ent
<br />11,,J11q9877
<br />2oWestlawn Memorial Park
<br />120d.Grand Island, Nebraska
<br />BA SIGNATU LICW
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<br />FUNERAL HOME —NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />/J
<br />pp
<br />22Livingston- Sondermann,505 W.Koeni ,Grand Islan�88Ne.
<br />DATE Of EATH (Mo., Day, Yr.)
<br />DATE SIGNED (Mo. Day, Yr.) HOUR
<br />Of DEATH
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<br />DATE SIGNED (Mo., Do %y, Yr.) MAO/ R OF DEATH
<br />f O �
<br />PRONOUNCED DEAD PRONOUNCED
<br />Yr.)
<br />DEAD (Hour)
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<br />(Mo.,-Day,
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<br />230 / 2�c. M
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<br />24c.
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<br />To the b «t of my knowledge, oath «cu d et IM nme, date end plow a due o the
<br />cauce(c)
<br />O. Me basic of —inotion end or i—fi ation, in m o
<br />opinion death «wr.ed of
<br />.toted.
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<br />v e
<br />IM Brno, dofe and Place and due b crotod.
<br />23d. (Sig -0— and Fitt.)
<br />24*. (S)pn -un end Title)
<br />NAME AN DRESS Of CERTI R (PH SICIAN, NER'S P fCIAN OR COUNTY ATTORNEY) (Type or Print)
<br />3F2 z ' e
<br />2A a 7-
<br />REGISTRAR
<br />DA RECEIVED BY REGISTRAR (Mo., Day, Yr.)
<br />26o.(aignetur.,►
<br />26b. JUL 1 7 1987
<br />27. IMMEDIATE CAU1446UE TER ONLY ONE AUSE PER LI JIJD (c)) Intenol between sncM and death
<br />PART
<br />1
<br />lwy_
<br />DUE TO, OR AS Interval byw- once) and doe
<br />DUE TO, OR AS A CONSEQUENCE OF: Ingrvol betty en and death
<br />Id
<br />PART OTHER SIGNIFICANT CONDITIONS — Condition. conM6uting to death bul not .doted ;ART
<br />111. If FEMALE. WAS THERE A • - AUTOPSY
<br />WAS CASE REFERRED TO M CAl
<br />AS SE
<br />PREGNANCY
<br />IN THE PAST 3 NTHS7 fsp«i!y
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<br />EXAMINER OR CORD
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<br />11
<br />(W
<br />w Ne)
<br />Yes ❑ Na 2B.
<br />2v. D
<br />ACCIDENT, SUICIDE. HOMICIDE, UNDEi.,
<br />DATE OF INJURY (Me., Des, Yr.,
<br />OUR OF INJURY DESCRIBE
<br />INJURY OCCURRED
<br />OR PEN INVESTIGATION. (Sp«iiy)
<br />1HOc.
<br />30o.
<br />30b.
<br />M 30d.
<br />INJURY AT WORK
<br />PLACE CN INJURY— At bemo, I -m, aveel, leclory,
<br />10CA110N STREET OR R.F.D. me. CITY W TOWN STATE
<br />(Sp«i/y Ye. - No)
<br />oNW "1411.9, etc. (Spedly)
<br />30e.
<br />300•
<br />
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