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1 DECEDENT - NAME MIST M00.E LAST <br />Jacquelyn Joy Brown <br />I <br />2 SEE <br />female <br />3 06 TS OE DEATH Mks* D e clan <br />December 15, 1999 <br />• CT Y A. STATE to mum. •aRRY5• ,..RaaYara <br />ea AGE W Oman. <br />rY..l <br />75 <br />LINDEN t YEAR <br />LIE'.' DAY <br />6 DATE OF SEI M+ Able. Dar coy <br />June 17, 1924 <br />Hastings, Nebraska <br />NOS ,. s DAYS <br />tar ws <br />x n <br />A 7 loom SWUM NAraEER <br />�/�C C <br />505 - 2z - 4s <br />ea PLACE OF MATH <br />,OEM ►K a mows D1tER ❑ <br />Ta wp Wow <br />R�aaea•/c. <br />�1 <br />�` FACUTY•NNW A owl wRMRRA .• tow AN/ .Vntit <br />Francis Heal th <br />❑ ER D..... 111 <br />II <br />O ca,t*YOFDEATw <br />__Memorial <br />96 61 690 1 E <br />le OTT TOWN OR Grand Island 1 Y.. 7 N6 ❑ <br />Hall <br />Ea RESEIEMCE . STATE <br />Nebraska <br />M COUNTY <br />Hall <br />et CITY TORN OR IOCATON <br />Grand Island <br />E/ STREET AND NUNIIER ,w adq SO Caw 1 es INSIDE CITY LINTS <br />2314 W. Charles 68803 Ea. No ■ <br />10 RACE • M{. 6Mtta. Dace A reign <br />9.11SCac+rl White <br />11- ANCESTRY ral3 YYl YNrtUI DY.tal t, <br />Iswwrt German /French <br />12 3 MARRED ❑ MOONED <br />• ❑ --co <br />a NAME OF SPOUSE ∎..t► EM faros.. ronwo <br />Roger Brown <br />14 uSUM DODUPATON 4- .FA.aaeRab.N0Yw ,,.., <br />A d .o.b p tea wow I' o atl <br />Homemaker <br />tat AND OF /USINESS INDUSTRY f IS EDUCATION ISpcaF CAR ngtall PtlN COmyw4 <br />Elt.+wyF.xa SacaaaRY 0 121 Cota3a 1 • a . •. <br />Domestic 11L2 <br />j N FATHER -NAVE FIRST l60 E LAST ii ...7,.. FIRST MIDDLE WIDEN SURNAME <br />George Kister Mary Francis Doggett <br />01NER SIGNIFICANT CONDITIONS- COWOK winding n M 9.id <br />, 9.ac,1 ....o <br />PART <br />6 <br />PART a /t6EMKE WA5 TREFN A <br />5 PREGNANCY IN THE PAST J MONTHS' <br />IAq.. 1.61 YN n No <br />Elm 2. AUTOPSY l2$ was Nat El 0• Mt D[y <br />J <br />1 1'A'RNER O 7 CONYV N -}. <br />v.. n p 1 N Y . IY 1 <br />-A y. 1 I L1- I <br />26a <br />ACC.0 .o 0 UfOM nwwad <br />. Stat.* ❑ APRON <br />❑ Hofoode If..a63F60n <br />DATE OF IRY (M OR VT) 2t HOUR OF 642.01 Y <br />360 FLA <br />M <br />260 DESCRIBE HOW NJWY OE .VRRED f-++ <br />2• INJURY AT WORN <br />1 <br />Yr, ❑ No ❑ <br />261 rL/�E of 1N.A1 A I 1n .1. <br />,, scow Weary <br />Oat . IM . 1E C (Spe <br />263 LOCATION STREET OR R F D NO .. / 1 OR TOWN S1 a r1 <br />,: <br />27a DATE OF DEATH (AN Dy YrA <br />December 15, 1999 <br />E 4 S <br />V <br />g a <br />° G <br />_ <br />Tea LATE SOWED , , Dar o I2b ISM • F PEAT.. <br />/ / M <br />4 <br />7 <br />270 DATE NED (Mb. Day 6,1 <br />SIGNED <br />l,Z /20 1 q`f <br />THE <br />7c MAIN <br />E OF <br />/3 M <br />264 PRONOUNCE DEAD ;Re DAY Y1. <br />�ls1 <br />1 2la.... 0 P0ONOuNt.t /DE la <br />/ // <br />0 OC. <br />27e TO Md brat d my 4noM036 6 6.61 . al mama 6m and owe and Our 9. 6.6 <br />0 0. 060060* Ral.e <br />IS?' ,' and TMs <br />.1 26• 0 tat Dam of w ar..a.06 awe O IMswawn n ., r co..0m" ✓n0 r <br />M 6f• Oat. a..0 Place a b d Due 6M [foals MAYO <br />/S4••••... aM 74'1 ► <br />29 DO T USE CONTRIBUTE TOT TM w <br />OOACC YES ❑ NO ❑ <br />30a HA$ ORGAN OR TI DONA BEEN CONSOERED' <br />S la.' <br />300 WAS CONSENT GRANTED <br />ES g<: <br />31 NAME AND ADDRESS OF CERTIFIER IPHYSICMN, • is R S P1OY51C4AN OR COUNTY ATTORNEY. . TrP• O Rear Dr. Sitki Copur, E. 211 e.. Grand Is],and, NE 68803 <br />32. REGISTRAR <br />____ <br />1 326 DATE FILED BY REG/STRAR *61 Dar I,l <br />1 DEC 2 21999 <br />-- t9 WAS DECEASED EVER W US AWNED FORCES'? <br />Ms we or a.Ia1 1 166. few A. 4W AWN d —.— <br />No <br />• <br />• <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />FEB 2 2001 <br />LINCOLN, NEBRASKA <br />1110 INFORMMM taAcce0 ADORES. <br />30 E - SIGNATURE $ LICERBE NO <br />FUNERAL <br />IM <br />STATE CR ) IASRA- DEPARTfENT OF HEALTH AND OMAN SERVICES FINANCE AND SUPPORT <br />VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />720 FUNERAL HOME ADDRESS /STREET OR Ai .D NO CITY OR TOWN. STATE. 211 <br />T ,« .FORrMNT . NAVE <br />Roger Brown <br />/STREET OR R NO. CTY OR TOWN STATE 211 <br />314 West Charles, Grand Island, Nebraska, 68803 -5899 <br />.4! .[x11 `! <br />216 NERCO CF 06POStCN 210 DATE <br />® Oral ❑ R.ra../ <br />Apfel - Butler- Geddes Funeral Home ❑ °"""°f ❑ <br />1123 West 2nd Street, Grand Island, Nebraska 68801 -5899 <br />23 *MEDIATE CAUSE RENTER ONLY CA PER U.IE FOR , u 611 AIaO 46a <br />— PART C0..C v Q C L t wY <br />201600054 <br />NLEY- S COOPER <br />ASSISTANT STATE REGISTRAR <br />HEALTH AND HUMAN SERVICES SYSTEM <br />12/17/1999 Westlawn Memorial Park <br />lid CEMETERY OR CREMM70RY LOCA MEd CITY :7R TOWN 5161E <br />Grand Island, Nebraska <br />99 149 <br />21 c CEMETERY ORCREMMID*V ...cemetery <br />....* bowmen were .r eN✓. <br />3wk� <br />N...s 6rrwn sNw a....r✓ <br />MI <br />1 DUE TO. OR AS A CONSEDUEN E OF k <br />M Mq_ce 'S VC sue c - o6M 6 /211(1 <br />DUE TO. OR AS A dettSEOUENCE OF <br />Icl <br />tfa..r 6mOmm ..r ..r nr✓ <br />