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4 Cr!Y AtiO YI #TE *sat.USA mmm Broken Saw, Nebraska 7 SOCIAL SECURTW NURSER 3e6.22.79S2 So RE ' • = STATE Nebraslka vim^ NMAI Denali 16. FATHER. NAME Ralph STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT, QU1 LTH AND HUMAN SERVICES IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE (RGIN L RCQ D ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICESA. L OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. . • 'n DATE OF ISSUANCE DEC : 02.2015 LINCOLN, NEBRASKA FIRST ON AMITY -:¢79r WroafAelifwtyw MAraMr'eRIWA L.E. Ray Park nabs & Highway 34 Sa. dTY. TOWN OR LOCATION OF . - TR Grand isiaad 1O RACE - Ie+F• INN, SIAM MIMOSA linear COUNTY USUAL 0 cUPATAX Ow rmGaswA Garr a ° W eld e r Lincoln, G 11. ANCESTRY M; iilrt laefr/YI Gnaw' MC4 AIihiN Q 6 19,3 FIRST MIDDLE * WAS OECEASE0 EVER VI U_ SEED FORCES? 7mm4. '1b 7ICOMAANT. NAME OA « ANL) I ow m Ism 1 08/13/1966 Emily VaaDyke 1,0 INFORMANT MAILING ADDRESS I$TREE? ORRF D ND, CRY oR TOWN STATE. aP7 Nebraska 68001 NAME Aptfel•Batkr- Geddes Fuse 23 SAMEOSATE CAUSE PART DROWNING ' 1M fi! DOE TO.OR AS A CONSEQUENCE OF DUE 70 OR AS A CONSEQUENCE OF btrpAWPAA STATE OF NURASSA — DEPAR"YE lT OF HEALTH SUMEAS OF VITAL STATISTICS CERTIFICATE OF DEATH us/ VaaDyke l y AOE - Ear& aw f is I � s F. 0477' y Island 1 PALMATION 1 Grand t to HM OF DUNNESS 9IOUST LASt VaaDyke a IETHODOF D ❑ Crenletsn ❑ D�tNer 220. FUNERAL NOME ADDRESS (STREET OR RFD. NO.. CITY OR TOWN. STATE 21117 1123 West Second Grand Island, Nebraska, 68801 -5899 kl T &Rest SGRIFX;A9R CONINTIONS- Consume eaantwong to ON dean ON I.t gNos a PLACE OF DEATH NOSPITAL 5 r NI *ace CRY moms 6e C00Y OF DEATH NT 1vie 94° 0 15 EDUCATION *ROY Oarl WINS reel ornplrA New Holland S'5 Seconewv 5 ,9 IENTER ONLY ONE CAUSE PER LINE FO11 U41ER! YEAR 50 T DAYS 7n $ Dw0RCEO 17 MOTHER FIRST Rath !01. AND k!f PRECNA CY NITRE VAS(2NgNTHSo 57s DATE OF (WAY!! ,NAM Dar ,, I A S U. 270. GATE SIGNED •9** DA Y, r teAE 1i E ## 276 TOe.eMaap a knowledge. Me Met. dale 0 dace and due N the caurN,l 01111110 P' sas /Swlr &M TM1S r j 277 OF DEATH I . 29 AID TOBACCO USE CONTREIITE TO THE DEATH? 300 HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED" a YE$ r] ND ex UNKNOWN [3 YES N0 34 NAME AND ADDRESS OF CERTIFER !PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEYI MOO PAN% ELLEN L. TOTZKE, HALL COUNTY ATTORNEY, GRAND ISLAND, NE 6880E 32a. REGISTRAR - Male September 2 SEX DA UAER t Y 6 *p! . DATE OF i7 190 MOO ., u Yam/ SC.. HDQRS tad* Apre E. STE5 RT AN0** *IER 7Ic114m M! 1023 S. Lh cola, 68801 '7 5 PRONOUNCED DEAD :W Dy. Tr) 9 -5 -95 Ow lr A0 mid SEAN Y SUC OOPER NEE W S,TATT REGISTR, R DEPARTMENT ©- HEALTH AND - HUMAN SERVICES ; F> ' OTHER 0 +A..NN Nome E We.aMle. OFer lSPaeb+ 43 NAME MUSK � MI OF U *3.* 49774 E' Kr y s MIDDLE 210. DATE 21a. CEMETERY OR CAE/NTORY. NAME 951 W MOEN SURNAME Lkyd 09/88/1995 I Grand Island City Cemetery 210 CEMETERY OR CREMATORY LOCATION CITY OR TOWN Grand Island, Nebraska UNKNOWN ELAINE & HWY 34 GRAND ISLAND, NE DATE STONED ,44n Day Yr ; [ 2E0 TINE Of - *ATP 1 2M. On e. e.anonsoun a' or emodooroan. on 617 050 duo end pace Joe gi'1 ovs ! 1/4. lea WAS TED'' YES I tn NO I mi SE ' 9 n P � 'Iw07 201508281 to MACE CRY L**ITS ..fti Cab,a n.a NINval WNMn Nest and 061116 Nowa'swoon onset ono omen Wows, Wham 0161111 and Dealt i POT Al of FEMME WAS THERE A - 1 74 AUTOPSY ) ,Apes 10.544 WA fl_ 1 1 j Yes LJ Na } OATEOF MJt7iW Hlb. DAY Yy RR HOUR OF NJURY r 26d. DESCRIBE How INuRYOCC.NKIED j0 0 ! 9 -5 -95 a PP1 ?60 p. I decedent walked into lake I " s.m. 0 PAWN 26r *WRY LC pF AT WORK I pL py 3 -Am. Iwo street INAOry 26q. 1.00ATION STREET DR R F 0 NC WY OR TOWN STATE Tae ❑ NP El CITY PARK 25. WAS CASE REFERRED TO MEDICAL EXAMINER / O9 CORONER , Yes No APPROX. 7: 00 p ., 2,0. PRONOUNCED DEAD Mauer 7: 1 p 5•1 STATE . "l'otzke