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<br />-Legal Description: Lot 3,
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<br />2, Knickrehm econd Addition
<br />County, Nebraska.
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS)
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />D OF ISSUANCE
<br />'SIR 2 8 2000
<br />LINCOLN, NEBRASKA
<br />HEALTH AND
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<br />200 2482
<br />STATE OF 11U11ASKA-- MwAffrjgXi Or NMTM
<br />WKAV OF WTAL STATIl U W DW M ,
<br />CERTI $ G 03284
<br />FICATE _ . _ _
<br />_ REST
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<br />. White Germa<< 67 11
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<br />aaaiesa.ar� ".
<br />- - ,. May 25,191
<br />CiTi WMA COUNM IMAMED. NIPM MAlRIED, NAME OF SPOUSE (N.r)(., oiw a.idsw.er..)
<br />WIDOWED !��!
<br />L ': , Garne - Nebraska
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<br />SOCIAL30amm MM1MR USUAL OCCUPATION (=kind of rL Jrw.1w(.R It1/iD UP WSIlfEiS OR MIOUSTRy COUNTY OF "ATM
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<br />CITY. TOMINORLOCA110110P DEATH
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<br />I wife :a. Home ,a Hall
<br />INSIOE CITY Umm MO3MTAl OR OTNER R�iTITUTION Noo. (N .N iw.i(i.r, M ►. OS a13T. »�IsM. DOA
<br />`Gr} and Island
<br />11100.06,119i «N.) .wEwmee.«r.g.,e.. n �.o
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<br />lldkt gr.an Memorial Hospital
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<br />I& Grand Is land ►ae. 220 S 21st ( Yes N.)
<br />11s,. 8
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<br />Cnrl — Wilson Minnie Mattieson
<br />WAS 09CEAitp EVER 1ld i?.S. AgEAED POKES?
<br />' (WK. 00 .w "am LM ,u. /Iw °w .N A.M. A »nie.l
<br />Ts Nor. • - - - '- - - -
<br />I,Robert Pool qHus band ,220 S 21 at,Grand Island,Nebr.6880
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<br />m, Riverside Cemetery Ind. Gibbon, Nebraska
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<br />fIN1ERIIL HOME —NAME AND ADDRESS (snEET of E r.a No, cm OR TpWN. STATe Ziry
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<br />2, Knickrehm econd Addition
<br />County, Nebraska.
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS)
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />D OF ISSUANCE
<br />'SIR 2 8 2000
<br />LINCOLN, NEBRASKA
<br />HEALTH AND
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<br />200 2482
<br />STATE OF 11U11ASKA-- MwAffrjgXi Or NMTM
<br />WKAV OF WTAL STATIl U W DW M ,
<br />CERTI $ G 03284
<br />FICATE _ . _ _
<br />_ REST
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<br />Mary Lot tie Pool Fe 19$2
<br />-2.
<br />e. HOURS, IwliS
<br />. White Germa<< 67 11
<br />CM ANff=ft OF 80W ( ..1 Iw U.S A,
<br />aaaiesa.ar� ".
<br />- - ,. May 25,191
<br />CiTi WMA COUNM IMAMED. NIPM MAlRIED, NAME OF SPOUSE (N.r)(., oiw a.idsw.er..)
<br />WIDOWED !��!
<br />L ': , Garne - Nebraska
<br />4. Q. ` S. A. to, Marr I,. Robert Pool,
<br />SOCIAL30amm MM1MR USUAL OCCUPATION (=kind of rL Jrw.1w(.R It1/iD UP WSIlfEiS OR MIOUSTRy COUNTY OF "ATM
<br />1z B A�\
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<br />CITY. TOMINORLOCA110110P DEATH
<br />x ... ; .
<br />I wife :a. Home ,a Hall
<br />INSIOE CITY Umm MO3MTAl OR OTNER R�iTITUTION Noo. (N .N iw.i(i.r, M ►. OS a13T. »�IsM. DOA
<br />`Gr} and Island
<br />11100.06,119i «N.) .wEwmee.«r.g.,e.. n �.o
<br />T e: a N» ..
<br />lldkt gr.an Memorial Hospital
<br />COUNTY
<br />,a,.,..
<br />STREET AM MAMM IN310E CITY LIMITS
<br />Na raala -; Ts►. Hall
<br />I& Grand Is land ►ae. 220 S 21st ( Yes N.)
<br />11s,. 8
<br />rw
<br />Cnrl — Wilson Minnie Mattieson
<br />WAS 09CEAitp EVER 1ld i?.S. AgEAED POKES?
<br />' (WK. 00 .w "am LM ,u. /Iw °w .N A.M. A »nie.l
<br />IM►Oi1MANT— NAME— REIATIONSNN— MAILIMd ADDRESS (STlET OR v.0. NO Cg1r OR TOWN STATE il►)
<br />Ts Nor. • - - - '- - - -
<br />I,Robert Pool qHus band ,220 S 21 at,Grand Island,Nebr.6880
<br />SUR1AL. CnwmNew. Rw. wra
<br />CEMETERY OR CREMATORY —NAME lOGT10N CITY OR TOWN STATE
<br />2o.. Burial. 10-82
<br />m, Riverside Cemetery Ind. Gibbon, Nebraska
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<br />March 6, 1982 : (Ma, oar, r..)
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<br />PHYSICIAN OR COON A EY) (),p..r grim)- -
<br />Gordon "J. Hrnicek,
<br />MD, 123 14 Custer, Ave, Grand Island, Ne 68801
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