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STATE OF NEBRASKA 23 IM PART tat 34. 4EG1$TRAR WHEN ` THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH 1S THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 9/20/2016 LINCOLN, NEBRASKA LAST se Stepanek 5a AGE • Last BYMay " 66 UNDER 1 YEAR Sb MOS 4 DAYS 2 SEX Female UNDER 1 DAY 54 . 0100 S SRNS I 1 DECEDENT. NAME FIRST. WOOL Rosyln Lou 4 CITY AND STATE OF EARTH ,e aptI, USA now* Ca4.71 1 Grand Island, Nebraska 7 SOCIAL SECUR'NY NUAIDER 507 -36- 2984 FACILITY -Name t, not nsaaaaL 9l.Maaaw andmntlw) How Community Hospita C LOCATION 0P lEATH St. Paul, Nebraska 9a RESIDENCE • STATE 19b'. COUNTY Nebraska Howard St. Pau 64 PACE - MET. MAIM. SNP .. .AmenFanINba6 11. ANCESTRY leg Mahan. M600844. Garman. 84, 12APQMARRIED etc l ISoec!NI White ISpeCay) � 140. USUAL OCCUPATION, ICA!.k 00 au*donedv KIND OF BUSINESS INDUSTRY ' ofwacaag At Ken 0,0+00 Housewi e ' Own Home • 1$ PATH[fj NAME F aTST::. . MIDDLE LAST ( dec d Walter T. Olsen 08 WAS DECEASED EVER>1N U5; ARMED FORCES '+ 19a INFORMANT. NAME no 04 unA I Y� � y 1 „YW�ddeNaa=an I Eddie Stepanek IU 1 INFORMANT MANGAODRESS (STREET ORRFD NO. CRY OR TOWN 51 ATE 25, 949 Hardy Road . St. Paul, NE 68873 A1. MER SIGNATUFIE&LLCEN$ENO Q Cy 21a METHOD OF DISPOSIT'ON 218 DATE ? ?lc CEMETERY ORCREMATORY NAME , � 4 , 7®so'I ❑Remo.a Apr 10, 200 • Elmwood Cemetery (1 228 - N ERAI. HOME - NAME 210 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Jacobsen ❑ Cfmlaum ❑ Dona,. Funeral Home ^t . Paul Nebraska 220 fUNSRAL HOME ADONESS STREET OR RFD NO CITY OR TOWN. STATE: ZIP) Oreenwav 411 "0" Street St. Paul, NE 68873 DIATE CAUSE EDLIEENCE 4ET0.ORASACONSEpt!__ „,„ OF .0VE TC/ OR ASArCON$EOUEO4OE OF ATE OF NEBRASKA- DEPARTMD T OF HEALTH AND HJ11AN SERVICES FINANCE AND SUPPORT "ITAL STATISTICS 0 3 04096 CERTIFICATE OF DEATH Danish/ � ib erman PAR7 OTTER SIGNIFICANT CONDITIONS • OY1d4ans Conlrlbue N the e death No not letal80 28N TATS OF INJURY 1Ab Day. WI 264 HOUR OF INJURY o � ''T A: cWe y Una a maned D 510080 0 Pr Hnmc'oe In: 94 CITY, TOWN 201606868 ea PLACE OF DEATH HOSPITAL a Moment D DOA 80 INSIDE CITY LIMITS I Be COUNTY' OF DEAT Yas No ❑ . Howard OR LOCATION 90 STREET AND NUMBER 0=4 17 MOTHER (dee) /ENTER ONLY ONE CAUSE PER LINE FOR ei :bl AND (011 PART III IF FEMALE WAS THERE 24 AUTOPSY PREGNANCY IN THE PAST 3 MONTHS, I I49es 10 541 Yes :Yes 2E4 DESCRIBE ROW INJURY OCCURRED e INJURY AT WORK 261 PLACEE OF INJURY . M home fa 51reet Iectory 26g LOCATION MIKP bu P.![ IS Yes No❑., bAle. OF DEATH ATp Dal'_ 5, R p}, \, a, c o3 8'275 DATE 54198512 rMe 21.F 277 TIME OF DEA TH 1274 Ti me bestol04 i eauses 844464 slSg 11,66. amdTAet9 410110;:2 1 41'�T ^° 5!ne dale and place 81 3 doe l4 me M DIU TODACCO USE CONTRIBUTE TCIT4IL UEATH 30 a HAS ORGAN OR TISSUE DONA a YES : NO UNKNOWN.. ( . El YES NAME AND ADDRESS OF CERTIFIETI ■RHY5ICIAN CORONER S PHYSICIAN OP COUNTY ATT00991. type or Pant- 2 8 A ril 6 2003 6 Day Vow) July 29, 1936 28C PRONOUNCED DEAD .hfi.' 000.911 On tall 635.5 of earn-nation the 1.•19 owe and place and 5w4nalule and Telel A r N CONSIDERED? 38 k NO OTHER ❑ N asing Home ❑ Reaatence 0 949 Hardy Road WIDOWED 13 NA:2E OF SPOUSE IN nde one made., camel f OIYORCER Eddie Stepanek 15 EDUCATION I5oece, onN highest Wade :onwbled) Elementary a Secondary 10.121 College 11.4 a 3.1 10 FIRST ':MIDDLE MAIDEN SURNAME Meta Grosch STREET OR RFD NO Cr Y OR TOWN $TATS U To Y^ -- c& u c G d x x I G \ � Ci u \ Y\- 3 DATE OF DEATH Woo. Osy VoYI lb¢AdegZip Creel 260 TIM0 OF DEATH WA$ CONSENT GRANTED ❑ YES APR 1 4 2003 STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 9e INSIDE CRY. LIMITS Yes ❑ ND� Interval beIWeen 09 511 410 110 0 0 21 between cnsol ann.. 10404541 between onset arm " Re: 25 W45 CASE REFERRED TO MEDICAL' EXAMINER OR CORONER Yes n No fx 285 PRONOUNCED DEAD Ih*.” myeshgabon..fl m OPmOn.10410 ,x al 481004314se LSlale0