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<br />Lot Six (6), Block Thirty (30) in the Original Town, Now City of
<br />Grand Island, Hall County, Nebraska
<br />1 9 1118 8 40 •rs -?-IF
<br />RVRW L�''J 20M078 �
<br />I HEREBY CERTIFY THAT THIS IS A TRUE AND EXACT COPY OF THE ORIGINAL A H %#rIZS7
<br />CERTIFICATE,,AND THAT I AM AN ACTING FUNERAL DIRECTOR
<br />of THE APFEL - BUTLER- GE'DDES FUNERAL 710'11E.
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH LICENSE NO.
<br />Amended BUREAU OF VITAL STATISTICS
<br />Dec. 17, 1980 CERTIFICATE OF DEATH ,
<br />DECEDENT -NAME FIRST MIDDLE LAST
<br />SEX (
<br />DATE OF DEATH (Mo.. Doy, Yr.) -
<br />1. Leonard Francis Forsman
<br />2 Male
<br />November 7, 1950
<br />RACE- (•.q., White, Block, Am•ricon ORIGIN /DESCENT(•. y., Irolion, Meniton, AGE -IeN RinMoy UNDER 1 YEA UNDER 1 DAY DATE Of BIRTH (Mo., Doy, Yr.)
<br />Indian, •k. (Sp•cily) German, etc.) (Specify)
<br />(Yrt./ MOS. DAYS HOURS MINS.
<br />.. l:}'iite s. American eo. 56 eb. 27, 1924
<br />;10
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<br />11.
<br />SOCI $�[U Nk�/+►oEl�. USUAL OCCUPATION (Gir• kind of work doM deriny med ND OF BUSINESS O INDUSTRY COUNTY Of DEATH
<br />/1 b.3bZS
<br />ofrorkin Gfe,•ranHnfir•d) 1"Creylitynds'Bus
<br />,�,. lanarer 1140.
<br />.' 13b. ne Hall
<br />CITY, TOWN OR LOCATION Of DEATH INSIDE CITY LIMITS HOSPITAL OR OTHER INSTITUTION- Nom. (If not in •iffier, HOSP. OR INST. Iwdical• DOA,
<br />JIF
<br />(Sp•cill( n m No) Rive •d d eumb•Q Owpati•M /Finer. R.., I.P.6-8 (SP-10
<br />Grand Island �es �ut�ieran Memorial
<br />,db ,k ,dd llospital ,de Inpatient
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<br />A ER -NAM fl MIDDLE LA THE - MAIDEN NAME FIRST MIDDLE LA
<br />11110 16 L••mil - -- Forsn IM Christina -- llammerscliml,
<br />WAS DECEASED EVER IN U.S. ARMED FORCES? INFORMANT- NAME- RELATIONSHf►-MAKING ADDRESS (STREET OR R.E.D. NO., CITY OR TOWN, ST l
<br />(V... .e, et "k) (11 ,er. eo...,u. end dater of re. ) ���-id 1
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<br />le. No _ ,v. Mrs: Frieda Forsman -Wife -1618 W. Louise-Grand Island, N
<br />BURIAL, Cr•marion, R•movol 11 EMETERY OR CREMATORY -NAME LOCATION CITY OR TOWN STATE
<br />Lvov. 10, 198, f
<br />20e. Burial 20b. 20K. Grand Island Cemetery god. Grand Island, Nebraska
<br />EMBA R SIGNATUR BE NO. FUNERAL HOME -NAME AND ADDRESS (STREET OR 4-F 0. NO., CITY OR TOWN, STATE, ZIP)
<br />21. ; 22.Apfe1- Sutler - Geddes 1123 t:l. 2nd, Grand Island, NE. 68801
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<br />�.. DATE SIGNED (Mo., Day, Yr.) HOUR OF DEATH _• -
<br />v 27b. Q V • D v z
<br />2Jc. / M W = 21b. lac. M
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<br />i° DATE OF DEATH (Mo., Doy, Yr.) e00 PRONOUNCED DEAD PRONOUNCED DEAD (Hour)
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<br />23d. 21d.
<br />NAME AND ADDRESS Of C 2d . M R If1ER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (type or Print)
<br />23. David Colan If.D. 729 N. Custer, Crand Island, PIE. 68801
<br />REGISTRAR '�� ,. RECEIVED BY REGISTRAR (Mo., Doy, Yr.)
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<br />PART Inrcnol b•nce- •stet end 1e•1k
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<br />DUE 10, OR AS A CONSEQUENCE Of: Iwtervo benn..n .n..t e.
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<br />PART O HER SIGNIFICANT CONDITIONS- C-diliem cenrribrrinR to d -rk bat �.I--d [FAII �11-A�' �1111'014 AUTOISY WAS CASE REFERRED TO MEDICAL
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<br />Lot Six (6), Block Thirty (30) in the Original Town, Now City of
<br />Grand Island, Hall County, Nebraska
<br />1 9 1118 8 40 •rs -?-IF
<br />RVRW L�''J 20M078 �
<br />I HEREBY CERTIFY THAT THIS IS A TRUE AND EXACT COPY OF THE ORIGINAL A H %#rIZS7
<br />CERTIFICATE,,AND THAT I AM AN ACTING FUNERAL DIRECTOR
<br />of THE APFEL - BUTLER- GE'DDES FUNERAL 710'11E.
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH LICENSE NO.
<br />Amended BUREAU OF VITAL STATISTICS
<br />Dec. 17, 1980 CERTIFICATE OF DEATH ,
<br />DECEDENT -NAME FIRST MIDDLE LAST
<br />SEX (
<br />DATE OF DEATH (Mo.. Doy, Yr.) -
<br />1. Leonard Francis Forsman
<br />2 Male
<br />November 7, 1950
<br />RACE- (•.q., White, Block, Am•ricon ORIGIN /DESCENT(•. y., Irolion, Meniton, AGE -IeN RinMoy UNDER 1 YEA UNDER 1 DAY DATE Of BIRTH (Mo., Doy, Yr.)
<br />Indian, •k. (Sp•cily) German, etc.) (Specify)
<br />(Yrt./ MOS. DAYS HOURS MINS.
<br />.. l:}'iite s. American eo. 56 eb. 27, 1924
<br />�. ,.March
<br />CITY AND STATE Of BIRTH (If net in U.S .A.,' 1.� CITIZEN Of WHAT COUNTRY MARRIED, NEVER MARRIED. NAME Of SPOUSE (if d., g;.� nloid•n nom•)
<br />nom• country) L� WIDOWED, DIVORCED (Specify)
<br />B,PIcLau ,Illin, South Dakota 9. U.S.A. 10. :tarried Frieda V. Scheer
<br />11.
<br />SOCI $�[U Nk�/+►oEl�. USUAL OCCUPATION (Gir• kind of work doM deriny med ND OF BUSINESS O INDUSTRY COUNTY Of DEATH
<br />/1 b.3bZS
<br />ofrorkin Gfe,•ranHnfir•d) 1"Creylitynds'Bus
<br />,�,. lanarer 1140.
<br />.' 13b. ne Hall
<br />CITY, TOWN OR LOCATION Of DEATH INSIDE CITY LIMITS HOSPITAL OR OTHER INSTITUTION- Nom. (If not in •iffier, HOSP. OR INST. Iwdical• DOA,
<br />JIF
<br />(Sp•cill( n m No) Rive •d d eumb•Q Owpati•M /Finer. R.., I.P.6-8 (SP-10
<br />Grand Island �es �ut�ieran Memorial
<br />,db ,k ,dd llospital ,de Inpatient
<br />RESIDENCE -STATE jc150bUNTY CITY, TOWN OR LOCATION STREET AND NUMBER INSIDE CITY LIMIT
<br />ISa. (Specify Yet or No
<br />Nebraska hall ,sK. Grand Island Isd. 1618 W. Louise Yes_
<br />,Se.
<br />A ER -NAM fl MIDDLE LA THE - MAIDEN NAME FIRST MIDDLE LA
<br />11110 16 L••mil - -- Forsn IM Christina -- llammerscliml,
<br />WAS DECEASED EVER IN U.S. ARMED FORCES? INFORMANT- NAME- RELATIONSHf►-MAKING ADDRESS (STREET OR R.E.D. NO., CITY OR TOWN, ST l
<br />(V... .e, et "k) (11 ,er. eo...,u. end dater of re. ) ���-id 1
<br />I
<br />le. No _ ,v. Mrs: Frieda Forsman -Wife -1618 W. Louise-Grand Island, N
<br />BURIAL, Cr•marion, R•movol 11 EMETERY OR CREMATORY -NAME LOCATION CITY OR TOWN STATE
<br />Lvov. 10, 198, f
<br />20e. Burial 20b. 20K. Grand Island Cemetery god. Grand Island, Nebraska
<br />EMBA R SIGNATUR BE NO. FUNERAL HOME -NAME AND ADDRESS (STREET OR 4-F 0. NO., CITY OR TOWN, STATE, ZIP)
<br />21. ; 22.Apfe1- Sutler - Geddes 1123 t:l. 2nd, Grand Island, NE. 68801
<br />t N el w..l.deo. d rrt at tM it-. it end plot• d MN tf1• On M• boric of •.o.inatlM end - it, r eNM, in . s
<br />c rl Need. / tiR y piwi•w d-M •coned of
<br />Z t. the 8.•, deb and pl «• end dw b IAe nut•(tl rror•d.
<br />yS Al
<br />`
<br />Sh 23o.(Siyne1 end lintel - iut0 24o. (Sienetere end Fill.)
<br />�.. DATE SIGNED (Mo., Day, Yr.) HOUR OF DEATH _• -
<br />v 27b. Q V • D v z
<br />2Jc. / M W = 21b. lac. M
<br />c . .
<br />i° DATE OF DEATH (Mo., Doy, Yr.) e00 PRONOUNCED DEAD PRONOUNCED DEAD (Hour)
<br />.•. ` S
<br />O (Mo., Day, Yr.)
<br />v
<br />23d. 21d.
<br />NAME AND ADDRESS Of C 2d . M R If1ER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (type or Print)
<br />23. David Colan If.D. 729 N. Custer, Crand Island, PIE. 68801
<br />REGISTRAR '�� ,. RECEIVED BY REGISTRAR (Mo., Doy, Yr.)
<br />�.�5 i
<br />2eo.rsi,nab.•1` ✓ / =" P
<br />27. IMMEDIATE CAUSE TER ONLY ONE CAUSE PER LINE TOR (a), (b), AND
<br />PART Inrcnol b•nce- •stet end 1e•1k
<br />It A W?Z /KroCA"
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Inre vat I.... on. ;.4 d..,-h
<br />TNT - 0SC mac..
<br />DUE 10, OR AS A CONSEQUENCE Of: Iwtervo benn..n .n..t e.
<br />(cl
<br />PART O HER SIGNIFICANT CONDITIONS- C-diliem cenrribrrinR to d -rk bat �.I--d [FAII �11-A�' �1111'014 AUTOISY WAS CASE REFERRED TO MEDICAL
<br />HS? (Spec l To No) EKAMINER OR CORONER
<br />2B.
<br />-
<br />ACCIDENT, SUICIDE, HOMICIDE, UNDET., DATE OF INJVRY (Me., Da,, r..l HOUR OF INJURY Df SC eDF HOw INJURY OCCURRED
<br />OR PENDING INVESTIGATION. (Ip «rfy)
<br />JOo. l LLit%L S 20b. TOc. M 30d.
<br />INJURY AT WORK
<br />(SP-1, Yer et N•)
<br />►LACE Of INJURY- At kame, fares,. N,e•t, factory,
<br />ol6ce boild-g. •1,. (Spe61,)
<br />IOCATION STREET OR R f.D. Na. CITY OR TOWN STAY!
<br />30e.
<br />]Of_
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />STATE DEPARTMENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br />A TRUE COPY OF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH
<br />IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DIRECTOR OF VITAI. STATISTICS AND ASSISTANT STATE RF.CISTRAR
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