|
rn = D
<br />-n
<br />O C) z R s
<br />u >
<br />n w ,n
<br />® n CM3 CAI p Cu
<br />(A � C= 1>
<br />vd rn
<br />M 0 =M CX3 O Ohs'
<br />a I�
<br />1 p '(
<br />1 1-A
<br />G� z m
<br />Cn
<br />p ..�
<br />rocs - —zy
<br />(Dcno�V
<br />DECEDENT -NAME f1lS DATE Of DEATH fM... 0". Yr.)
<br />n nm
<br />1
<br />RACE- (e.q.. WINl., Bl.dl, A..riU.. o NWANIMSCE NT(e.g..*.Ii...M..icoo. ASE -I.N @.IA&.,, UNDER T YEAR UNDER T DAY DATE Of BIC"(M... Day, Yr.)
<br />Iwd ". Nsi(sy« •f�r) G.rrAew..EC.)fSp«dr) f bl frrR.l S. DAYS HOURS . MIN$.
<br />1 oat. 26 1887
<br />d. White S. German ". eb. eC. ,.
<br />CITY AND STATE OF BIRM (N no :. U.S A., CITIZEN Of WHAT COUNTRY MARRIED, NEVER MARRIED, NAME Of SPOUSE (N.il., qi.. w..:d.w wew.)
<br />MM cove~►) WIDOWED. DIVORCED fSpscor)
<br />Sohle Holstein Germ USA 1o. Widowed I-
<br />O n cu m
<br />ICOUHTTOPOEATH
<br />J..e►RiwB lifi....w i/r.Ar.d1
<br />J113e. Homemaker l.113b. Home ide. Hall
<br />x �j 0 0 M
<br />(SP- Y s a No) vie ~ and somber)
<br />14b. Grand Island 14c. Yes 1.d.I,utheran Memorial Hospital tal 1w. Inpatient
<br />P) a U) rt
<br />WHEN THIS COPYCARMES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUN►AWSERVICES
<br />F-1 In N rt
<br />x
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECO JI6 ORFILE.WITH
<br />~ C O p A)
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/STIGXWCTION, WHICH -IS
<br />n (D t-h 0 H
<br />THE.f.WAL DEPOSITORY FOR VITAL RECORDS. =
<br />O tj pi
<br />� rt fi
<br />CEMETERY OR CREMATORY -NAME LOCATION CITY OR TOWN STATE
<br />�r (t O
<br />DATE OF ISSUANCE rl�q
<br />me. tab- 3/2Z79
<br />EY S . COOPER =
<br />FEB 0 2001
<br />E
<br />C `-' ► i
<br />Cn rt*
<br />1 ASSISTANT STATE REGISTI�1t ^
<br />LINCOLN, NEBRASKA HEALTH AND HULK/ NSERVICES SYST IY _
<br />O O rt'
<br />Z y 0 rh (D
<br />=
<br />(D O rt
<br />22.
<br />(A
<br />r .1 W id. tsirr.•+.r rN.i --
<br />fi (D �:r O
<br />7 3c. 4.26 PM ��= 2db. 24. M
<br />(D
<br />_
<br />N �v N rt
<br />NAM AND ADORE EtT ER ( PHYSICIAN• CO EWS PHYSICIAN OR COUNTY ATTORNEY) (Typo or P—t)
<br />a ro `� o
<br />2 0 01012 5q sTAm of mm au— of NEIILTN
<br />iO
<br />eu"w of MAL SUM= 79 01969
<br />y rt In
<br />CERTIFICATE OF DEATH
<br />( ►)
<br />DUE TO. OR AS A CONSEQUENCE OF: .we e.wlA
<br />lei --E-
<br />PAR1j OTHE /e11 AN O"O/TIO"S- C.wd,w.we.MI.IlNIw dNIA b.$...,eI.Nd I PART III, N FEMALE, wA3 MLR! A AUlO►S WAS CASE REPERREo TO MEDICAL
<br />PREGNANCY IN IM! PAST MONTNSI (Spou Y .• Nol ERAANNQ OR CORONIA
<br />ISp «•h Y.. w NO
<br />II
<br />�•ti U No
<br />DECEDENT -NAME f1lS DATE Of DEATH fM... 0". Yr.)
<br />Dora Christina Thesenvita 2.Female 13 February 27 1979
<br />1
<br />RACE- (e.q.. WINl., Bl.dl, A..riU.. o NWANIMSCE NT(e.g..*.Ii...M..icoo. ASE -I.N @.IA&.,, UNDER T YEAR UNDER T DAY DATE Of BIC"(M... Day, Yr.)
<br />Iwd ". Nsi(sy« •f�r) G.rrAew..EC.)fSp«dr) f bl frrR.l S. DAYS HOURS . MIN$.
<br />1 oat. 26 1887
<br />d. White S. German ". eb. eC. ,.
<br />CITY AND STATE OF BIRM (N no :. U.S A., CITIZEN Of WHAT COUNTRY MARRIED, NEVER MARRIED, NAME Of SPOUSE (N.il., qi.. w..:d.w wew.)
<br />MM cove~►) WIDOWED. DIVORCED fSpscor)
<br />Sohle Holstein Germ USA 1o. Widowed I-
<br />B.
<br />SOCIAL SECURITY NUMBER U KINDOF BUSINESS OR INDUSTRY
<br />ICOUHTTOPOEATH
<br />J..e►RiwB lifi....w i/r.Ar.d1
<br />J113e. Homemaker l.113b. Home ide. Hall
<br />12.
<br />CITY, TOWN OR LOCATION Of DEATH INSIDE CITY LIMITS I HOSPITAL OR OTHER INSTITUTION - N.Iw. (N w0 is oirb.r, 10 MOSP d MIST I.d.e... DOA,
<br />O.'�w"•"gE.« t.. - 0 - (sp«/rl
<br />(SP- Y s a No) vie ~ and somber)
<br />14b. Grand Island 14c. Yes 1.d.I,utheran Memorial Hospital tal 1w. Inpatient
<br />RESIDENCE -STATE COUNTY CITY, TOWN OR LOCATION STREET AND NUMBER INSIDE CITY LIMP'S
<br />tsp.c+ Y«.r N.)
<br />1s.. Nebraska 1s►. Hall 1sc. Grand Island 13d. 0 East 10th St. u.. es
<br />- Au MOTHER - MAIDEN NAME FIRS MJDD4f LAST
<br />Theodore Nissen Christina Peterson
<br />WAS DECEASED EVER IN WS- ARMED FORCES?
<br />FSURIAL.
<br />INFORMANT- NAME - RELATIONSHIP- MAILING ADDRESS (STREET W t 1 D NO. CITY Olt TOWN, STATE. ZI►I
<br />w w.. « w.Il I I•I Y••..^• — wad d.rw N ..,.•../
<br />19. Clarence th- Son -Alda Ne 68818
<br />Cr.wwtiew, R.w..ol DA
<br />CEMETERY OR CREMATORY -NAME LOCATION CITY OR TOWN STATE
<br />Island C god. Grand Island
<br />me. tab- 3/2Z79
<br />rand
<br />AIMER- s/GNA[URE i LICENSE NO.1820
<br />FUNERAL HOME -NAME AND ADDRESS (ST1111 of R r D No. CITY O1 TOWN. STATE. ZW) 613801
<br />J I
<br />st d ' 0 Ko ni Gr Is; d Ne
<br />21
<br />22.
<br />T. w a w sa. -M+t. aA ~.veal w/ w A.., wN w"d ..r d.. r w s w 0�i...•1.. e—d.. rMw - - —1 —P"». d..IA .......d W
<br />r .1 W id. tsirr.•+.r rN.i --
<br />�Li
<br />7 3c. 4.26 PM ��= 2db. 24. M
<br />23b.
<br />i DATE OF DEATH (M.., Day Yr.) s 9 PRONOUNCED RAID PRONOUNCED DEAD (Mo.r)
<br />S Day, Yr.)
<br />i (M...
<br />V
<br />23d —Aft- - - M
<br />NAM AND ADORE EtT ER ( PHYSICIAN• CO EWS PHYSICIAN OR COUNTY ATTORNEY) (Typo or P—t)
<br />W. J. Landis 14.-D., 2444 F&ddley Ave.p Grand Island 21e.
<br />23
<br />1 REGISTRAt D� V -tD 6Y tE IStRAR (Moo. Doy. Yr.)
<br />ed •/
<br />'V4. 2e
<br />2ee.rs.Rw.r.•.1►
<br />IMMEDIATE UuX. fj+(ift ONl ONE CAUSE PER PINE FOR ( , fb). AND (c)/ Iw «..« « •wa d«IA
<br />PART
<br />1
<br />P
<br />(.1 R AS A CONSEQUENCE OF: o"d I...
<br />( ►)
<br />DUE TO. OR AS A CONSEQUENCE OF: .we e.wlA
<br />lei --E-
<br />PAR1j OTHE /e11 AN O"O/TIO"S- C.wd,w.we.MI.IlNIw dNIA b.$...,eI.Nd I PART III, N FEMALE, wA3 MLR! A AUlO►S WAS CASE REPERREo TO MEDICAL
<br />PREGNANCY IN IM! PAST MONTNSI (Spou Y .• Nol ERAANNQ OR CORONIA
<br />ISp «•h Y.. w NO
<br />II
<br />�•ti U No
<br />Y 1 Li►+1 l Yo. :' 2e 29
<br />Attla "t, sllltloe. M R a Iwu pESCRISE NOW INJURY OCCURRED
<br />a PENDING NNESTIGAT30..
<br />!;;;
<br />30R. M 30d. *UU1Y A WOn - AI Ao... foal, 0-1. I..". LOCATION STRIET OR ■ I 0 M. CITY OR IOW" STATE
<br />M u.I c (SPO.drl
<br />rt (D 10
<br />(D U) G
<br />�n ft 0)
<br />o n
<br />O IO rt
<br />ort n
<br />rt m M :2�
<br />F'( F 1
<br />z� zv
<br />Q) rt- LT1
<br />W g \\
<br />Cn W
<br />(D F-1
<br />�J b \Sy
<br />t✓ (D
<br />^ p) (n
<br />� F1 rt
<br />C:) rt
<br />(D P) r'
<br />F1 H (D
<br />Fn �j
<br />(D En
<br />rt F-1 O o
<br />\ r-
<br />O J�:- rt
<br />t_b U) �3 A)
<br />rt N ITJ r i
<br />I V H- (D
<br />(D IP 1'11 (A rt
<br />v
<br />aN ' C o
<br />rt O i 1-h
<br />•,.3' ' " O
<br />.s rf
<br />(D �3'
<br />(o
<br />
|