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<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 />DATE OF ISSUANCE
<br />MAR 1 2000 ASSISI .
<br />LINCOLN, NEBRASKA HEALTH AND HUI
<br />NEii f MAN 4ERWES
<br />ZSlV FR�l�I%R'H
<br />Lv
<br />ANLEY S. COOPER
<br />VrSTATEREG /STf AR
<br />IN SERVW"YSTEIF
<br />U►�U�B$4
<br />STATE OF NEBRASKA — DEPARTMENT OF HEALTH 95.00790
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />1 OEOEOOIT -alA1E ,HOST 1100LE LAST FF2,-,,
<br />J DATE OF DEATH ;ua aM ✓vA" T- awm"nm Tm Mir}ipl eale I January 14. lqqri
<br />A C M AND STATE OF 61111 OmW O. G SA Aaw oearFTV -"—
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<br />s DATE OF BFRH rAbIH LEb YANG,
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<br />nz1 58
<br />November 13, 1936
<br />7 90cm SOCURFIN MI1LeEJl ea PEACE OF DEATH
<br />HDSPTTAE ® I — OTHER ❑ F.,,.., Hrwa
<br />505-38 -5420
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<br />TS COUNTY OF DEATH
<br />t CITY TORN ON LOCATION OF 01SATI." 8a "SIDE CITY LIMITS UN
<br />Grand Island, Nebraska Y. RR - ❑ Hall
<br />•t RESIDENCE -STATE
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<br />2020 W. Wau h S.X!
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<br />No ❑
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<br />1`I IAA White " American FI NEVER DIr -ED Jimmy E. Michel
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<br />Accounts Receivable Dept. Country General Stores 1 3 Yr.
<br />16 FATHER -NNW FNST MIDDLE LAST 17 MOTHER FIRST MIDDLE WIDEN SURNAME
<br />Ellsworth NMI 'lucker I Velma NMI _
<br />_Hauberk____
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<br />216 DATE ^— 171c CEMETERY CA CREMATORY NAAE-
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<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 />DATE OF ISSUANCE
<br />MAR 1 2000 ASSISI .
<br />LINCOLN, NEBRASKA HEALTH AND HUI
<br />NEii f MAN 4ERWES
<br />ZSlV FR�l�I%R'H
<br />Lv
<br />ANLEY S. COOPER
<br />VrSTATEREG /STf AR
<br />IN SERVW"YSTEIF
<br />U►�U�B$4
<br />STATE OF NEBRASKA — DEPARTMENT OF HEALTH 95.00790
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />1 OEOEOOIT -alA1E ,HOST 1100LE LAST FF2,-,,
<br />J DATE OF DEATH ;ua aM ✓vA" T- awm"nm Tm Mir}ipl eale I January 14. lqqri
<br />A C M AND STATE OF 61111 OmW O. G SA Aaw oearFTV -"—
<br />% AGE - L,r eFlm.r
<br />DAr
<br />s DATE OF BFRH rAbIH LEb YANG,
<br />DF�
<br />Grand Island, Nebraska
<br />nz1 58
<br />November 13, 1936
<br />7 90cm SOCURFIN MI1LeEJl ea PEACE OF DEATH
<br />HDSPTTAE ® I — OTHER ❑ F.,,.., Hrwa
<br />505-38 -5420
<br />❑ RardI-
<br />❑
<br />ER OWIam.
<br />L! FACILIn - INOn OF.W Amm mE AF 2~&W Maw
<br />❑ 0OA El 6i -,,;*, ---
<br />St Francis Medical Center
<br />TS COUNTY OF DEATH
<br />t CITY TORN ON LOCATION OF 01SATI." 8a "SIDE CITY LIMITS UN
<br />Grand Island, Nebraska Y. RR - ❑ Hall
<br />•t RESIDENCE -STATE
<br />a COLOR►
<br />9c C17Y. TOWN OR LOCATION
<br />9e STREET AND NUMBER lA'fAA%v
<br />CITY LIMITS
<br />Hall
<br />rand Island
<br />2020 W. Wau h S.X!
<br />�68803
<br />No ❑
<br />HH RACE - M0. Wl.a. awk — aHsAn I I AMCESTRY H 9 um. 10--am Gm emw 112 � MARRIED ❑ WIDOWED 17 NAME OF SPOUSE if -41 q✓. �+.�^ n 1
<br />1`I IAA White " American FI NEVER DIr -ED Jimmy E. Michel
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<br />a,.wlgafe.mH.AareI@ 33 Elm ArYaSxa.dry10121 C~11A..s-I
<br />Accounts Receivable Dept. Country General Stores 1 3 Yr.
<br />16 FATHER -NNW FNST MIDDLE LAST 17 MOTHER FIRST MIDDLE WIDEN SURNAME
<br />Ellsworth NMI 'lucker I Velma NMI _
<br />_Hauberk____
<br />IS WAS DECEASED EVER N US M\E77 FORCESI Igo INFORMANT NAME
<br />Vo r1.ay N�A E. Michel
<br />ITO NFOIV~ IW1Ri ADDRESS ISTREETORRFD NO CRYORTCWN STATE 21P1
<br />2020 W. Waugh St. Grand Island, Nebraska 688_0_3
<br />A TUREt 110
<br />21• UFFHODOFD POSITON
<br />216 DATE ^— 171c CEMETERY CA CREMATORY NAAE-
<br />❑8,.,.I ❑Far.ANr
<br />an. 18, 1995 _,Central NE.Cremation Servic
<br />INERAL HOME NAMI
<br />214 (EAETERY OR C.REMAI CRY LOCA ICM1 CITY(R FOWN STATE
<br />Kleine Wiest Funeral Home
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<br />ibbon, Nebraska
<br />226 FUNERAL HOME ADDRESS (STREET OR RF D NO CITY OR TOWN. STATE 2P1
<br />3213 W. North Front St. Grand Island, NE. 68803 --
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<br />and TAN Y iV / ` A l C �.E�` V� 1
<br />•_sad i4I R
<br />OO TOBACCO
<br />USE CONTRIBUTE 70 THE CEA 19a
<br />HAS ORGAN OR McAA DONATION BEEN CONS" RED' �D WAS C(NISEN7 C,MNTED,
<br />❑ YES ❑ NO 111A0aDWM
<br />❑ YES Ek, ❑ YES rg-*�NO
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