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I DEGEDBR -MANS t Aa100LE LAST <br />Roger B. Highland <br />2 SEX <br />Male <br />3 DATE OF DEATH ANN ON YON' <br />1 December 6, 2003 <br />• CITY APO STATE OF WV. ,Ptrw USA mow aaawN4 <br />Sweetwater, Nebraska <br />54 AGE • W yalaq <br />"" 87 <br />,AIOER 1 YEAR <br />UNDER , DAY 6 DATE OF /MATH .Marl, Ow poly <br />S° laDS °"� <br />x H0 November 25, 1916 <br />7 SOCIAL MQ.WTn NUMBER <br />508-38-1734 <br />ea PLACE OF DEATH <br />H o - L E `°". c,_ J D <br />ER OwreI _` . <br />111 <br />❑ DDA ■ <br />........ <br />P noence . <br />Dee,* <br />• <br />i FACILITY - polo ar Ap alaaMaNa )l4 <br />1317 N Kruse Ave. <br />t CRY TORN OR LOCATION of DEATH <br />Grand Island <br />$0 INSIDE CITY UNITS <br />Yr 4 No ❑ <br />Ala COUNTY OF DEAN <br />Hall 1 <br />!6 F- SPENCE.STATE <br />Nebraska <br />IN COMITY <br />Hall <br />6c CITy TOWN OR LOCATOR <br />Grand Island <br />9a STREET IANMILIEEP mnuaayzlLoeb - A. WIDE CRYLWS <br />T317 N Kruse Ave.688133..7 Na <br />10. RACE - Ng- WINE sack Amman roan. <br />.e1*SIaIey1 White <br />I t. A;.4....TRY Ng. KAMA Macao Gawk NO <br />I America <br />I2 ® MARRED ❑ MOONED <br />[] NEVER D n D1YORCED <br />t3 NAME OF SPOUSE t/.A* ,M wa ' tW.W <br />Esther M. Alter <br />7• USUAL OCCUPATION IGtrlbdd•a. deNdngnear I NS. MD OF BUSa1ESS INDUSTRY <br />d wom*at wow anarm <br />Petroleum Delivery Pe troleum Distributor <br />73 EDUCATION (Sow* o NAM gram. =MONO <br />E -- "°S.cabay. 1 o :1.a5 <br />'1$ <br />16 FATHER -NAME FAST SADDLE LAST <br />Loren Carr Highland <br />17 MOTHER FIRST PADDLE MWEN SIATINAAW <br />(Unknown) (nmi) Braun <br />15. WAS DECEASED EVER N US ARMED FORCES? <br />crew.. a lAW.I I AllS 9.0w Oro alas MsaW Sl <br />YQC� I WWII 6/11 - 11/30/45 <br />19.. NFOBsANT - NAME <br />Esther M. Highland <br />185 WP i1ANT LWIIG ADDRESS (STREET OR RFD NO_ CITY OR TOWN. STATE ZVI <br />1317 N Kruse Ave., Grand Island Nebraska 68803 <br />20. EMBALMER - SIGNATURE a UCBLSE NO <br />( Not Embalmed ) <br />21a saETHOO OFDISPOSTON <br />U Bumf • Rama. <br />FrA. Demean Donacn <br />215. DATE <br />Dece913ei 7, <br />1- 21c CEMETERY OR CREMATORY NAME <br />Central Nebraska <br />ema t ry i C <br />22a FUNERAL HOME - NAME , <br />Kleine Funeral Home <br />Wii Tat <br />210 CEMETERY OR CREMATORY LDCATIOR clfTE <br />Gibbon, Nebraska <br />225. FUNERAL HOME ADDRESS *STREET OR RFD. NO.. CITY OR TOWN. STATE ZIP* <br />3213 W North Front St., Grand Island, NE 68803 <br />23 *MEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR : at t5L AND loll - tea' e. aue one Hair <br />PART (31 / ,/ / / �l /� <br />* NI W� �Ca <br />DUG Taco AS A CONSEDUEN etwva Oelllaatl anal a,a aeir <br />ICU 10 T LUKL <br />DUE TO. OR AS ACONSEQUENCEQF W4„a Ww•••• onset me aoaa <br />(d <br />0Z (F�1EER SIGNIFICANT C - CCatlwla ceNONq L lea d/1 IPA ry/I Nlsne /JA. PREGNANCY E M THE PAST MONTHS, <br />PM7f <br />M ! r O Y a 1 V/ \ f V f.a �. i Da e <wk /,1 a l (MK 10 -5.1 Yes L No [J <br />2 AUTOPSY <br />Yes No Y <br />25 EXAMINER w. � a1. SIEDDCN. <br />OR COFIONE <br />YOs 1 "' V , <br />26s. <br />0 ❑ A 1hbt ❑ Uldalamwla0 <br />Surma • Penang <br />0 HOns[da <br />285. DATE OF INJURY ON. 17/ <br />Mc HOUR OF INJURY 1 263 DESCRIBE HOW NJURY OCCURRED <br />M <br />26a. INJURY AT WORN 2M a�ca . PA Aa`E of g SOaCMI Ae, _ . lam weal Mary <br />Yea No ■ �d0nN.1URY Smlr <br />269 LOCATION STREET OR P F D. NO CITY OR TOWN STATE <br />a1 <br />LJ <br />27a DATE OF DEATH pb. Day Yr.) <br />M (,/ D 3 <br />F. <br />! W I <br />.2 t.t <br />3 <br />20a DATE SIGNED IAN Day n7 <br />/2. (13 <br />2B5 TIME OF DEATH <br />law 35 M <br />270. DATE ! / AN. Day. VTJ <br />/i /! Q� <br />27c THE OF DEATH <br />M <br />29c P DEAD :Ab Day. Yr! <br />/a2 / 1 <br />260 PRONOUNCED DEAD <br />/3 7 M <br />270. To the bed d my Neadedge. Oath occuneS ■9 ME. ME amigos and Waa b the <br />camels) Med. <br />(Sonars and • <br />, /1 <br />26a On Me bee SWSIwde, And a AMN6aaOn. n my moan Oaas, OCQAMA al F <br />Me Ina. Owe and plan. b MN cnwtlsl steed a <br />i and Tak1 • <br />J '! a /// <br />TOBACCO NT <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH 30a HAS ORGA @OR TISSUE DONATION BEEN <br />— EEN <br />❑ YES 1/f NO 0 UNKNOWN YES E <br />NS1OE DT <br />1 NO - <br />30 W CONSENT DT - , <br />YES NO <br />31. NAMEAND SO OF CERTIFIER (PHYSICIAN. CORONERS PHrgap*N OR COUNTY ATTORNEY) t reps a Po Pon ` 7 "' <br />RAell 23 / • ZQ r S r & � (o AFL <br />32 .. REGISTRAR <br />intikilfik i p - , , <br />325 DATE FILED aY gEGN57RAR Rao. Day r" <br />DEC 152003 . <br />STATE OF NEBRASKA <br />0601619 <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 ORIGNk RECORD ON <br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES,"' TA 5 RECORDS <br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />2/26/2016 <br />LINCOLN, NEBRASKA <br />• <br />ANLEY -I . QpPER . <br />ZLSSISTANT STATE REGISTRAR <br />EPAR T OF EALTFI AN <br />mu iC&S s • <br />STATE OF IORAH A- DOZADMADIT OF HEALTH AND HUMAN HDIVICFS Fl NCE AND SUPPORT <br />CERTIFICATE OF 03 14137 <br />DD EA,H <br />