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<br /> r WHErI THIS COpY CARRIES THE RAISED SEAL OF THE NEBRASK(� STAT�`— �oa473
<br /> � DEPARTMENT OF HEALTH, IT CERTIFIES TNE BELOW TO BE A T�tUE COPY �
<br /> � OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTI�N�?.0�' HEALTR
<br /> BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPQS`L�QRY FOR'
<br /> VITAL RECORDS. �
<br /> �!\'_1C, , . ,
<br /> �', � �i�.
<br /> DATE OF ISSUANCE ``[��� ;�,`,
<br /> vAN t� � STANLEY S. Gf}OBTs�,.;�ZR�:G�T�bR'
<br /> LINCOLN, NEBRASKA BUREAU OF VITiA�'f�+��'I$�•IES
<br /> � �A��S REAU OF YR�L STAT�ISTICS HEALTH g 9 118 8 6
<br /> CERTIFICATE OF OEATN ;'
<br /> 1 OECEOEHi•N�4E F�qST 41001E IAST 2 SE■ �3 OATE OF OEATH 4Ur:�pa. �tJ•
<br /> Irwin Ben�amin Peterson Tlale : Octobe.r 21 , 198Q
<br /> � GI7V�ND$iATE OF 81RiN inrorm u5• rumr covmri Sa AGE•tu�B�n�aai 6 O�iE O�9�pT� umn D�. +er
<br /> vn� S� MOS 'J��S Sc MO�QS R�iNS
<br /> Mason Ciey, Nebraska 79 Feb. 8, 1910
<br /> 7 $OCU�SECU�Nuu18Ep �f ��110E OF OEATM
<br /> NOSDITI,L _�np�i��l �ER�u7�iP1n1 =OpA
<br /> - 505-32-814I �'sL++f� �Nv��mu�• -�sA•�c. _ano,so.�Ar,
<br /> dp iACLm/•NMM !H rol Mt7t�OW�yW fhNt 1N�W�!DMi !C CT'TOMM OR LOCATepN pi DEATM M INSiOE GITV IIWTS p� COUNTr Qi pf_ATH
<br /> $DIC YHW�MDI
<br /> St. Francis Medical Center Grand Island � �es Hall
<br /> - 9!NE$�MC: S1ATE W�tiMTY YC G�r TOMM OQ IOG�TiON 90 $TAEET�NO NUMBEA i��[NO.nq2�p CPOli 9f Ih$47E CiN t�1MT�
<br /> Nebraska Hall Grand Island 821 So. Arthur `�es`��°
<br /> t0 RACE-I�q MrtiM.&an ArwtaninCUn tt AMCESIRY��p.IW�y�W:K�n 6artunMt� �2 WRWEDNEVER►URHiED �] N�11EOf$POUSE �n�MQr�MAMiyny�
<br /> Me 1 I''Me 1 Nn00WE0 �VOi�CEO�SDCeAp
<br /> te �,inerican G6 Marr�ed Julia C. Porter
<br /> �N USUAL OCCUPATIQN!(iM t�M W�pr�0py aurvy mp�t ttD�liNO 0�BUS�NESS iNDUSTRY �
<br /> d�Oremp tM.�r�n n nerN h 1� /`Q' ENxnuM1 a S�tonaary�D��4� Co�yq���.�a S•�
<br /> ./ Funeral D�rector � �uneral Service 5+
<br /> i8 FA7YIER•NANE F:RST 4�JOlE tAST i7 IdpTnEA•Y�tOEN NAME (�RST n1i001E L�ST
<br /> Nels William Peterson Mary Theodocia Nicholas
<br /> tE WAS OECEASEO EYER M U S AHA1E0 fORCES° �9 iNiWWANT•NAME•M�4�4G ADDRE55 �ST�tEET QF R G O h0 CT'OE1 TON�N ST�if.�PJ 1
<br /> (MH.M,a J�R 1 (N yM.OM�L iM GW W N�vKHI
<br /> No ulia Peterson-Wife-821 S. Arthur-Grand Is and, NE.
<br /> 7W OURAL GMna�w�.R�maY 20b OATE 10c CEMETEar Op CAEM�TpqY�tiAYE 20a lOCn7�W+ pTV OR TOwN ST�TE
<br /> °oiMOr Oct. 25, 1989
<br /> Burial Grand Island Cemetery Grand Island, Nebraska
<br /> M E NATUpE• SE NO O Yl iUNERAI HO4E•NA1AE AND�ODiiE55 lSTPEET Op A F D NO C�T'Op T01MN STATE.21P1 ' h
<br /> pfel-Butler-Geddes 1123 W. 2nd, Grand Island,6�01 ., i .
<br /> T USE �� IENIER QNLY QNE CAVSE PEN UNE FOA 1 1 IDI AND Ith tntavai MhNn pnsN�tn
<br /> VART � •
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<br /> OUE T0.OR AS A SEOUENGE OF �nuna�wrw�/n o�,se+ano oe-aa- -�.
<br /> OUE T0.OR AS A CONSEOUE Oi , �nNna�Mt.w�nC_ YW O�iM - .
<br /> p�OTNER S�GNiRG1NT qhpfTlpNS•Cd�Omont tOnn�dArp q G�m DW ro�r�iriW PAq7 III�F FEMA�E WAS TMERE A 2� A Sr t5 WAS CASE REiE E TO MEDKA� �
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<br /> 26�ACG�ENT.SU�C10E.M0IYGDE.UNDET 4db DATE OF�NJUR� lM0.01r vil 28t HOUP OF IN,IURV j�p pE$Cq�BE MQW IN,JVAY OCCUpAED
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<br /> �� 27D DATE SH3NE0 I+w.O�r.Y�1 77c 7iyE Oi OEATN��, �� ?C[ �WONOUNCEO UEAD d/o D�r Y'� 2L0 PpONOuNCED OE�O �no��:
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<br /> � s� t70 ta er Ont d my tno�t�oq�.0�� carw n tn�u�n0 dac� c a � tM On me casa d�■am�.aw�am a��ns��qaro� ��+r o:o�o+oean occ��•w ai
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<br /> 2➢� plp TOOACCO USE C T 7E TO THE OEAT + 70 MAS OAOAN Op T�SSUE OONAiiOti BEEN ONS�OEaEO' JOO W�5 C'Jh5E4t GA�NiED'
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<br /> �31 NlJE�NDADORESS OF CENTIFIEq�PM/$�CAN.CORONERS ONY51C4H Op COUNTV AtTOHNEV� (1�q y P�.nh
<br /> _ __ Robert R. Koefoot M.D. � 727 N. Custer, Grand Island, NE. 68803
<br /> �2�REGiSTRAR 7t0 D�tE qtED 8•QEG�S�Z ��•� .-'---___-_-__
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