|
x'
<br />A'I
<br />M
<br />M
<br />r)
<br />7C
<br />m
<br />-e,
<br />c�
<br />y..
<br />WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL READ (W0ILE W- ITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC$ECOC K "*74ICtt -IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />rJ�Al1E ffY Ss COOP
<br />DEC 2 2 2000 ASSIgANT STA tE RE(#ISTRAR
<br />LINCOLN, B l yl O A J HEAL TH�AND Hi� iMt-SERL/CESSYSTEiI
<br />1 2j
<br />- STA?E OF NEBRASKA +- DEPARTMENT O/ IRAL
<br />BUREAU OR VRAL STATISTM j�
<br />CERTIFICATE OF DEATH
<br />732
<br />... r ' Fred LDTB
<br />bale 06- 26-94
<br />wDiR x DAY a w Y,,,1
<br />t 4 "M A. A1fl�FN1MF,
<br />S" AOE tAfta"+AIE"Ir
<br />Nowt
<br />i
<br />D
<br />i6-bAf*(*s*t"
<br />k O1 -I1 -19
<br />Ball::Dotm
<br />507-48 -65 9 '
<br />104!", L Q `e. THEM ❑ lot 0 �.P.
<br />.,
<br />go CA Dmpnrl Q �..
<br />• NIAII 1EeotAMM►lMf r+Atwu antAprl
<br />i
<br />❑ °Q" ❑ o»,s.�.�
<br />o
<br />C-) cn
<br />Is CITY TO"EIp1 ttl
<br />r
<br />Igo 0"Il OF DEATH ".
<br />GiWN ISLA1tD1B 68801
<br />r."] TII ❑
<br />HALL CD
<br />E ". r. 011"
<br />M E N�ttrTw CsY"'
<br />t" MID" UMISS•
<br />NEBUI >cs
<br />HATM I CD `
<br />ALDA
<br />7862 v GuEr = RD
<br />z
<br />N
<br />CD
<br />....._.
<br />Me= 140 U9Lft OOCAPAfM IO"1Wdw"~A/r."rl 10 KIID OF 3USINE95 NDUSTRr 11 EDUCATION 15M.._ imp" wow CON~
<br />IT"MNyMM /MNM' : '� UPON" of" O t71 COME" 1„a'*•I
<br />I J iculture _ (� „
<br />Farmer jV
<br />Is 1AWIN-0614111 MGD►6 LAST 17
<br />r 1
<br />O
<br />rn
<br />O
<br />• N W& ARCED PORCM
<br />IN INFORMANT wAME
<br />IY"LAA.M) rwaMwwANr/rftTYl01y
<br />M
<br />f� TOARFON0,011VORTOWkSIA1121M
<br />7862 W. Guenther Rd., Alda, NE. 68810
<br />i EMIALMEl1 • aKi1A • NfO
<br />21" IET1N000F DEPOpTKIN
<br />_
<br />21I DATE 2k. CEMETERY ORLII MAtC*' NAME
<br />.
<br />❑ Nr"t"•e
<br />June 29, 1994 Alda Cemep!a
<br />Oft NIOIE MAIN
<br />O
<br />0L'""'" 003""Asm
<br />fel- Butler - Geddes
<br />CD
<br />Alda, Nebraska
<br />M FUNERAL 1101E ADDRESS, IEtIE•EI QA R/ D NO CITY OR I STATL 211
<br />1123 West Second, Grand Island, NE. 68801
<br />U MEDIATE CALM (ENTER ONLY ONE LMM.,E PER LIE FOR to Ipt AND It:N MMWt INN~ aM am o•"",
<br />►Ali
<br />I. t
<br />L4K/
<br />A MII NrAPwtrl""waMrwll"n
<br />DUETO.OR A OF
<br />� �
<br />W in ORASAWMEEgENCEOF ►+w"Itwwn~&Vduw
<br />Iq
<br />OTHER SIONAFCANT CONW004 • Ce"II""" 03OP&A y 0M • P OW ANA. PART
<br />■ IF FEMALE WAS THERE A
<br />AUTOPSY
<br />w
<br />O
<br />N THE PAST 7 MONTHET
<br />124
<br />ERMnER OR COFKM A I
<br />M
<br />ft"" 10-6" Y"" ►f"
<br />YN No
<br />Y" No
<br />N•
<br />NI DATE OF 1NA0W rb OW *4
<br />2h ~OF RL&M
<br />S 0II c CNNEO
<br />-1r
<br />N
<br />CD
<br />❑ suoo. ❑ ft-0
<br />aI P AIRY AT WORK
<br />as PL/ALE OF M • N." q Is. W""t YI 1
<br />260 LOC ATCH STREET OR RFD No UT T OR fOAV t STA1f
<br />D
<br />CIl
<br />�ASStwi /sPNfAr
<br />278 DATE OF DEATH lu" Oft NT/
<br />2" DATE SIGNED- 1W Day Y l
<br />2b TAE OF OEATIf
<br />..�;t
<br />00
<br />CAI
<br />Ul
<br />C
<br />"
<br />E
<br />M
<br />s
<br />..
<br />a
<br />a" MYM.Nr INfAlo"wwe�iwer w��a"w o.c,.wnr
<br />270 to ft 6W Of ^M aNR OtxaNN r"r r"a I"N.wrNn warty
<br />�•,ye
<br />c"trra N>.a
<br />"
<br />wT
<br />wT
<br />21, DID TOvACCO
<br />USE CONTPIWIN TO THE DEATH7 ]Da
<br />HAS ORGAN OR TISSUE DONATION BEEN
<br />CONfSIDEIEDT
<br />301 WAS CONSENT GRANTED? .�
<br />11 rES ..... 0 NO ® W.-tow
<br />® YES
<br />NO
<br />YES IN f►D
<br />WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL READ (W0ILE W- ITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC$ECOC K "*74ICtt -IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />rJ�Al1E ffY Ss COOP
<br />DEC 2 2 2000 ASSIgANT STA tE RE(#ISTRAR
<br />LINCOLN, B l yl O A J HEAL TH�AND Hi� iMt-SERL/CESSYSTEiI
<br />1 2j
<br />- STA?E OF NEBRASKA +- DEPARTMENT O/ IRAL
<br />BUREAU OR VRAL STATISTM j�
<br />CERTIFICATE OF DEATH
<br />732
<br />Cheryl Bodeen M.D. St. Francis Medical Center, Grand Island, NE. 68803
<br />In. Aft— 13ft DATEFE.EOFfFEOSTRAR R4 ANP Nv7
<br />,n
<br />t'd (n — z F3
<br />• (D to O �Y
<br />�3: n N F( (D
<br />OFtmm
<br />x�30ww
<br />a 0i m rF
<br />F1 (D
<br />C O b pi
<br />0 (D F-h r H
<br />G F
<br />rt Fi
<br />�- �y L•t O
<br />rt --T (D (D Fh
<br />ft
<br />O O �31
<br />Z H 0 Fh (D
<br />tr $ �v rt cn
<br />Fi �J (D �3' O
<br />wcnP) cD0
<br />(n �' (n rt
<br />aro `�0 �
<br />H 0 ft U)
<br />((D N
<br />�n &P)
<br />C1 H
<br />O Q rt
<br />z "' a n
<br />O rt F(
<br />* :3' rt
<br />rt (D (D
<br />(n \
<br />O N
<br />7d r. z (n
<br />P) rt tai ::�
<br />::$ J'FAF-
<br />LQ :� \ \
<br />(D (D
<br />H rt �•
<br />� b�:V4
<br />G (D
<br />F 1 Fj �• ft
<br />ort
<br />(D A) rt
<br />U) �
<br />:E,--0
<br />(D U) -.
<br />U1 trJ En F�
<br />rt N0 0
<br />t-h En �v P)
<br />rt N N'rJ fi
<br />\ F'• (D
<br />(D to Fh (n
<br />. . rt
<br />rn t-< 0
<br />rt 0 t ttI
<br />N31 Fh O
<br />rt
<br />... r ' Fred LDTB
<br />bale 06- 26-94
<br />wDiR x DAY a w Y,,,1
<br />t 4 "M A. A1fl�FN1MF,
<br />S" AOE tAfta"+AIE"Ir
<br />Nowt
<br />w1 M
<br />,' ", Nebraska
<br />to
<br />.'75
<br />i6-bAf*(*s*t"
<br />k O1 -I1 -19
<br />Ball::Dotm
<br />507-48 -65 9 '
<br />104!", L Q `e. THEM ❑ lot 0 �.P.
<br />.,
<br />go CA Dmpnrl Q �..
<br />• NIAII 1EeotAMM►lMf r+Atwu antAprl
<br />Medical
<br />❑ °Q" ❑ o»,s.�.�
<br />St.- Francis Center
<br />...,._.•
<br />Is CITY TO"EIp1 ttl
<br />No ."SIDE Ott L M S
<br />Igo 0"Il OF DEATH ".
<br />GiWN ISLA1tD1B 68801
<br />r."] TII ❑
<br />HALL CD
<br />E ". r. 011"
<br />M E N�ttrTw CsY"'
<br />t" MID" UMISS•
<br />NEBUI >cs
<br />HATM I CD `
<br />ALDA
<br />7862 v GuEr = RD
<br />._.�.�
<br />10 RACE to 0. am A0440 It M9 SMi111. 11t"cfn Go No rli q ®MRAM OWKiOWEO 13 NA14 OF SP'DUSi N"fI 0"IATIIM• /IITMf
<br />"r►TEIrtI� HBITB "~`"1" American `> NEWT oFlaxxo DoRmin Wilhelmi
<br />....._.
<br />Me= 140 U9Lft OOCAPAfM IO"1Wdw"~A/r."rl 10 KIID OF 3USINE95 NDUSTRr 11 EDUCATION 15M.._ imp" wow CON~
<br />IT"MNyMM /MNM' : '� UPON" of" O t71 COME" 1„a'*•I
<br />I J iculture _ (� „
<br />Farmer jV
<br />Is 1AWIN-0614111 MGD►6 LAST 17
<br />MOTHER FIRST NMI WIDEN
<br />William Luth
<br />Dora Nissen
<br />• N W& ARCED PORCM
<br />IN INFORMANT wAME
<br />IY"LAA.M) rwaMwwANr/rftTYl01y
<br />Dorothea Luth .
<br />f� TOARFON0,011VORTOWkSIA1121M
<br />7862 W. Guenther Rd., Alda, NE. 68810
<br />i EMIALMEl1 • aKi1A • NfO
<br />21" IET1N000F DEPOpTKIN
<br />_
<br />21I DATE 2k. CEMETERY ORLII MAtC*' NAME
<br />.
<br />❑ Nr"t"•e
<br />June 29, 1994 Alda Cemep!a
<br />Oft NIOIE MAIN
<br />210 CEMETERr OR CREMATORY LOCATKY" City A:Ity'rMN STATE
<br />0L'""'" 003""Asm
<br />fel- Butler - Geddes
<br />Alda, Nebraska
<br />M FUNERAL 1101E ADDRESS, IEtIE•EI QA R/ D NO CITY OR I STATL 211
<br />1123 West Second, Grand Island, NE. 68801
<br />U MEDIATE CALM (ENTER ONLY ONE LMM.,E PER LIE FOR to Ipt AND It:N MMWt INN~ aM am o•"",
<br />►Ali
<br />I. t
<br />L4K/
<br />A MII NrAPwtrl""waMrwll"n
<br />DUETO.OR A OF
<br />� �
<br />W in ORASAWMEEgENCEOF ►+w"Itwwn~&Vduw
<br />Iq
<br />OTHER SIONAFCANT CONW004 • Ce"II""" 03OP&A y 0M • P OW ANA. PART
<br />■ IF FEMALE WAS THERE A
<br />AUTOPSY
<br />_
<br />12b WAS CASE REFERRED TO MEDICAL
<br />PMT P•TEGNANCY
<br />N THE PAST 7 MONTHET
<br />124
<br />ERMnER OR COFKM A I
<br />I
<br />ft"" 10-6" Y"" ►f"
<br />YN No
<br />Y" No
<br />N•
<br />NI DATE OF 1NA0W rb OW *4
<br />2h ~OF RL&M
<br />S 0II c CNNEO
<br />❑ ❑ �W
<br />M
<br />❑ suoo. ❑ ft-0
<br />aI P AIRY AT WORK
<br />as PL/ALE OF M • N." q Is. W""t YI 1
<br />260 LOC ATCH STREET OR RFD No UT T OR fOAV t STA1f
<br />' 11It"LT"" "o"UPA"A
<br />'
<br />YN Q q" Q
<br />�ASStwi /sPNfAr
<br />278 DATE OF DEATH lu" Oft NT/
<br />2" DATE SIGNED- 1W Day Y l
<br />2b TAE OF OEATIf
<br />270 DATE SGWD 114 ON, yr 2h I" OF DEATH
<br />2II: PAONOINCED OEM Atb ft Y,1 2M PROOMWAD DEAD It+tlA/
<br />C
<br />"
<br />E
<br />M
<br />s
<br />..
<br />a
<br />a" MYM.Nr INfAlo"wwe�iwer w��a"w o.c,.wnr
<br />270 to ft 6W Of ^M aNR OtxaNN r"r r"a I"N.wrNn warty
<br />c"trra N>.a
<br />"
<br />wT
<br />wT
<br />21, DID TOvACCO
<br />USE CONTPIWIN TO THE DEATH7 ]Da
<br />HAS ORGAN OR TISSUE DONATION BEEN
<br />CONfSIDEIEDT
<br />301 WAS CONSENT GRANTED? .�
<br />11 rES ..... 0 NO ® W.-tow
<br />® YES
<br />NO
<br />YES IN f►D
<br />Cheryl Bodeen M.D. St. Francis Medical Center, Grand Island, NE. 68803
<br />In. Aft— 13ft DATEFE.EOFfFEOSTRAR R4 ANP Nv7
<br />,n
<br />t'd (n — z F3
<br />• (D to O �Y
<br />�3: n N F( (D
<br />OFtmm
<br />x�30ww
<br />a 0i m rF
<br />F1 (D
<br />C O b pi
<br />0 (D F-h r H
<br />G F
<br />rt Fi
<br />�- �y L•t O
<br />rt --T (D (D Fh
<br />ft
<br />O O �31
<br />Z H 0 Fh (D
<br />tr $ �v rt cn
<br />Fi �J (D �3' O
<br />wcnP) cD0
<br />(n �' (n rt
<br />aro `�0 �
<br />H 0 ft U)
<br />((D N
<br />�n &P)
<br />C1 H
<br />O Q rt
<br />z "' a n
<br />O rt F(
<br />* :3' rt
<br />rt (D (D
<br />(n \
<br />O N
<br />7d r. z (n
<br />P) rt tai ::�
<br />::$ J'FAF-
<br />LQ :� \ \
<br />(D (D
<br />H rt �•
<br />� b�:V4
<br />G (D
<br />F 1 Fj �• ft
<br />ort
<br />(D A) rt
<br />U) �
<br />:E,--0
<br />(D U) -.
<br />U1 trJ En F�
<br />rt N0 0
<br />t-h En �v P)
<br />rt N N'rJ fi
<br />\ F'• (D
<br />(D to Fh (n
<br />. . rt
<br />rn t-< 0
<br />rt 0 t ttI
<br />N31 Fh O
<br />rt
<br />
|