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STATE OF NEBRASKA 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 IS THE LEGAL DEPOSITORY FOR VITAL RECORDS GATE OF ISSUANCE 10/1 7/2016 LINCOLN, NEBRASKA STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES S DATE OF DEATH Noah /My *WI March 18, 1997 & OAT&OF IRMO AMKW DPP RAW October 17, 191 MAnroN s�,RNAME Rayno 1. DECEDENT . NAM Arthur 4 CRY STATE OF s NAM so USA raalwANA19N Grand Island, Nebraska VANIER 505 -14 -1933 NA FACILITY -6«r 416 N. Ruby 9c CITY TOWN OR LOCATION OF DEATH Grand Island >k RESSOENZE -STATE Nebraska IN RAGE ,99..9.9.. Slade Mrwica. Man .at's9s t e I :14 USUAL OCCUPATION KN LATdaIPaa dnAMNIAg moot AYw ham Alt Roo YAWN*, Carpet Layer FF4Sr 910 .lames Ta r9AL5 DECEASED EVER ++ us ARMED FORCES? rr «mar WC) pTNr 9nawAnd d.srviaU : PATFIEN -NAME Alnd axRANA, �r.NNvMyldnWtiv; EA COUNTY Hall Milton Yes ,Jan. 194 45 201607010 MIDDLE Ralph $TAT€ OP N.EURASKA — OSPARTMENT Of WALTS SWUM Of VITAL STAT1*TICS CERTIFICATE OF DEATH Goodwin 54 AGE • Last 0/6 n1 78 B& PLACE OF HOSP A !N I6S&7S LAST Y« ® ND Et ...,. 198 INFORMANT JARMO ADDRESS (STREET NO CRY OR7 416 N. Ruby, Grand Island, Ne. 68803 2Ti M0TIODOF DLSP0S7906 /�• OCA .tak 1143. ® nA, ❑ >u SIGNATURE & LCETASE NO 224 FUNERAL NONE • NAME Livingston -Sondermann F.H. ❑cn D ° '"ab°n 178 FLINERY. SCAM ADDRESS . 'STREET OR R.F.D. NO CRY OR TOWN. STATE ZIP) 601 N. Webb Rd., Grand Island, Ne. 68803 -4050 23 YEWTE CAUSE .`gyp 1� (ENTER ONLY ONE CAUSE PER LINE FOR I6 bi. ANO Ica w OWE TO. OR AS A CUNSEOUENCE OF art DUE TO. OR AS A CONSEOUEIerE OF PAR* OT7GTIFICA NT OON(R?ONS - Ca10Par a s lone d.9n Dana laded E3 'a ❑ WWRPnariad ❑s ❑F.—, ❑ T>a wda NmaaagaaM 1Ta. DATE DEATH /M,.. DINT Y,) 798. DATE OF INJURY (Ma Yr) NU INJURY AT WORK Y« No 6 I pdart t l , Wm Nowt Maw 0— 0 ER O pawn Q DOA E: CDLIRY OF DEATMU Hall 9c. cRY. TOWN OR LOCATION 9d STREET AND MASS tawb.6.92*Oa3at: Grand Island 1416 N. Ruby 68803 WAT 11, ANCESTRY 1,.9- I May G. n..,. oft) ISM MA9gED a WDOWED NM,E OF SPOUSE /Mare P�/sada Mil* SCO /Fr U 0 0° Irene Schrader lib KIND OF SUSAYESS INDUSTRY 1ON- ISP9PNy PINI AgrM grid. °WV*S* oleo 5. EDUCAT Carpet ar Pala - CPr90 11- 0 •I Self - Employed /Installation e LAST:: 17 MOTHER FIRST Goodwin Idella 119. Wf0RMAf NAM 9 T -E Irene Goodwin 29c HOUR CF INJURY 1 29 WORN DESCRIBE HOW OCCURRED OTHER 0 193maa rwHonor � R.rOanes 0 /3 IaOOLE Mary 7! THE OF OdR'if:: 218 DATE 21c CEMETERY OR CREMATORY - NAME March 21,1997 I Westlawn Memorial bark 21d CEMETERY OR CREMATORY LOCATION Car OR TOYMA STATE Grand Island, Nebraska t PART n IF FEMALE WAS THERE A . 12. AUT°PSt PREGNANCY IN PIE PAST ' 3NIONTN6' } ^ IARta 10-o9) Yaq:, ` ` N° n Yvs. I I Ib 26g. LOCATION STREET OR970 NO CRY OR TOWN a l9 9a Io&CTTYLoos Yas WQ 9 9. brood cam am ASK 25 WAS CASE REFTSOFIED TO MeSICA1. TtAAa ri ATE 278 DATE D AIb Day :Y, re THE OF DEATH ': C 2!C PRONOUNCED DEAD AMo 970 Yr.) 7I6 PRONOUNCED DEMI (Non 29 7 2:07 P.M. DC TPM«ararmy darn «comeNM..- . And dui b a. ma ° 23, On.+ ad . r aar.rw• aro ^r a M�WM'rry«•+I «n aa^a.aw.rsdaA N:allar9 !.Naar. — 9 vow dY ArtN d-°. Arid bra b h womb+.«.& � �( � i 9Sgna TON _. 11' .� tsookA•and TMl• w USE CONTRlJTE TO THE DEATH? 3Da JAS ORGAN OR TISSUE DONATION SEEN OONS OERE0° 30.0 W AS comae' 6RAN7ED'N � K YES . 0 NO 0 UNKNOWN Y 0 YES Y 0 YES X. I NAME AND A} E95 OF CERTIFIER ( PHYSICIAN. CORONERS PHYSICAANOR COUNTY ATTORNEY f 1T,9aa P,M, /:"." t.. N`1., b2-. Dr. Stephen Budd, 14.0 a 6 `r 320 DATE FILED BY REGSTgW A b LNR' N) ... MAR 2 7 1997