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DECEDENT -NAME' HEST ! MIDDLE LAST S <br />SOT' D <br />DATE Of. DEATH (M... Oey. Yr.) <br />tact-4, Ilierb. Americo, OR�dH/DESCENT(a.R., Naha -. A <br />AGE —Imo Ii I diy . - <br />- UNDER 1 YEAR I UNDER 1 DAY - D <br />DATE Of BIRTH (Mo.. Der <br />MOS. : DAYS { <br />UR <br />am AND STATE Of (N oar he U.S.A.. . CITIZEN Of WHAT COUNTRY M <br />MAIMED NEYERMARRTED, N <br />NAME OF SPOUSE(1(.Pf., *T'• -.1d.. ae.z.) -.: <br />SOCIAL SECUNTY NU11SEI U <br />USUAL OCCUPATION ( <br />(Vac kW ohmic des. d.rift wed • R <br />RIND'0f BUSINESS OR INDUSTRY C <br />COUNTY Of DEATH ' <br />CITY, TOWN CO LOCATION OF DEATH I <br />INSIDE animas " <br />,..71 t <br />"NOS AL OR OMER INSTITUT/ON —Nave Of Alf in *Aber. 1 <br />1 NOW. OR 11/ST. Iadk.$."DOR: • <br />RESIDENCE—STATE C <br />COUMY C <br />CITY, TOWN OR LOCATION • S <br />STREET AND NUMBER I <br />INSIDE CRY OMITS <br />(Specify Tar or Ne) <br />FATHER-. [ i�ME" NUT : MIDDLE LAST M <br />MOINER —MAI NAME FIRST MIDDLE t*S1 <br />WAS DECEASED EVER Di U.S. ARMED FORCES? I <br />INFORMANT NAME — RELATIONSHIP— MAJ(NG ADDRESS (STIRRT OR R.F.O. NO.. C(1r OR TOWN. SPATE. TR) . <br />MEN, Ci.ec iea. RoccolDATE C <br />CEMETERY OR CIEMATORY — NAME ' L <br />LOCATION . CITY OR TOWN ' STATE <br />s(GNIURE a LICENSE NO. 21 F <br />FUNERAL HOMk —NAME AND ADDRESS (STREET OR RES. NO., OTT 01 10WN. STATE. Oil .. . <br />H ... 4:13214 1 .7471 <br />14.0E CIA (AM:. Day Yr.J D <br />DAtE ST(i01EO (M.. 0.� Yr.) H <br />HOUR OF DEATH .. . <br />(M M <br />HOUR Of DEATH • <br />•pw <br />UV UNDO, w <br />Akflitlik401103 <br />PRONOUNCED DEAD P <br />PRONOUNCED DEAD (New) <br />O() lww M <br />M 2 <br />NAME,AIfO ADDRE Of cannot( E RS PH YIICIAN OR COUNTY ATTORNEY) (Typo er him) <br />2 ' G.D.' Penner,.M.D. . 1408. -. 5th St. Aurcira. Nebraska - 68818 <br />FIEG(3TRR,R '. D <br />DATE *EC ED. IT REINSTR* (Al... Day, Pr.) <br />--, .. ENTER ONLY ON SE PER UNE (eL (111; AND (c)) : Iw■n.1 IONA.. ANN Awl Edo* '. <br />a ]C`1i L OY► / • 1 ' 1 141 c <br />• .: OR A CONSEQUENCE Of. .:.INnwl balsam ...N <br />DUE TO;,OR AS A CONSEQUENCE OF: .' IN ,,.� aft* .d ••" : .' . <br />• Id i . , , <br />p Re piorcon CANORIONS C..dili..a .a4lnl.fas 4o area fat co n4,4 , P <br />PART Ia. I WS T A ? U <br />UTOPST . W <br />WAS JfiECK� . ' comer <br />ACCIDENT SUICIDE: NOb LIDE.'4111041. D <br />DAPS 01 WANT NA., D.y, ;T,. N <br />Noun OE sDUR! f <br />ffri <br />1141LRIr,AT WORE - P <br />PUKE OP WNW Po laws, lanc,a1 .,Iaau,. L <br />LOCATION ' . i . STREET OR RED. N. . CRY,OS TOWN $ATE „`f <br />STATE OF NEBRASKA <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND <br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON <br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECD, ZDS <br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />STANLEY " OOPEI <br />A•SSTSTANT STATL,REGISFRAR <br />QEPARTMENT QF HE,4�-LTH AND <br />bl I!4AN S kt7CE <br />DATE OF ISSUANCE <br />11/13/2015 <br />LINCOLN, NEBRASKA <br />STATE :OF SE RASKA- DEPARTMENT "OF HEALTH <br />EUREOZ,OF VITAL STATISTICS <br />CERTIFICATE OF DEATH / <br />