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<br />LAST 1 17 NDTHER FMeSt MIDDLE MAIC44 SURNAME
<br />(Dec.) Gus Lemburg i (Dec.) Dora Becker
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<br />i ?esa 1 X rT %3%46 /19/47
<br />Frances Lembu_�
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<br />190 WFORMAM MAILING ADDRESS (STREET OR RF 0 NO CITY OR 10101N CTATE 2VI
<br />619 E. Grand Island,
<br />Nebraska 68801
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<br />RE: Lot Two (2), Block Twelve (12), Joehnck's Addition to the City of Grand Island, Hall
<br />County, Nebraska.
<br />WHEN TM COPYCARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN4&RVI_CES
<br />SYSTE14 R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICBSE�ijpV044 $,_
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - -
<br />DATE OF ISSUANCE
<br />MAY 17 2000 = AA01
<br />ASSI37; $TA RPGISTR¢R
<br />LINCOLN, NEBRASKA HEALTH AND HUIIIgN S SYSIYi
<br />200004200
<br />STATE OF NEBRASKA — OE►ARTMENT OF HEALTH
<br />BUREAU Of VITAL STATISTICS
<br />CERTIFICATE OF DEATH 9 6' 1 3 5 1112
<br />DECEDENT - MAINE, piKT MIDDLE LIST 2 SE% _ 3 GATE OF DEATH �•bnn DAr YN +i - --
<br />LeRoy August Lemburg Male November 5, 1996_
<br />CRY AAD STATE OF B9E /N At,R, A M SA. ,IP,M FAMIFM SA AGE - L.AM &Mft UNDER I YEAR UNDER. ( DAY ! DATE OF OR. H ,AbM DA yI
<br />`x" 69 wYS 5' wkm MNS September 22, 19'2.7
<br />Baanebrog, Nebraska
<br />- - --
<br />T. DDGIAL Y$IPITIf I!A1A�11 - - M (LACE OF
<br />507 24 1998 HDSl ©` " DTHEA ❑ Fill He, I,
<br />9n F ACILIT'll Nw1R ATP '*WAWA VIV 101F, &V M~ ❑ ER 0I00« ❑ A.POrr,
<br />VA Medical Center, 2201 N. ,Broadwell ❑ DOA ❑ aN«ISPAF/.. --
<br />9c CRY T. , ON t.00ATIONGF MATH EF M COWTY OF OFATN
<br />Grand Island, Nebraska YN © NO ❑ Hall
<br />OR RESIOENGE • STATE Xl � `,;,eRTV 9e CRY. TOWN OR LOCATION ; Sell STREET AND NUMBER ;IYwn•'19 ZO Ca , 1 90 INSIDE CITY LNAMGTY TS
<br />Nebraska Hall Grand Island 619 E. Bischeld 68801 YN E, . ❑
<br />10 RACE -to 9. MAIN. 111Aq A,IRIgw IlOMI 1 11 ANCESTRY R q NNIL 1M.IFML G..WI, ill 12 ® MARR,EO wriowEO j tl VAME OF SPOUSE.... F.M "mAUr
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<br />16 FATHEP. NAME FIRST MIDDLE
<br />LAST 1 17 NDTHER FMeSt MIDDLE MAIC44 SURNAME
<br />(Dec.) Gus Lemburg i (Dec.) Dora Becker
<br />19 WAS OECFASED EVER N u ARMED FORCES?
<br />,90 INFORMANT NAME _-
<br />i ?esa 1 X rT %3%46 /19/47
<br />Frances Lembu_�
<br />-, _- - - - - -- - -- - --
<br />190 WFORMAM MAILING ADDRESS (STREET OR RF 0 NO CITY OR 10101N CTATE 2VI
<br />619 E. Grand Island,
<br />Nebraska 68801
<br />BBischeld,
<br />20 IMEt CE D
<br />2tA ME THODDFDISFOSITON 1210 DATE 11c CFMETE%W OR C.REMA1ORr NAr.,E
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<br />�] ❑ W�IOrM ; Nov _ $, 1 g9 Dannebrgg Cemet_�y
<br />j10 CEMETERY OR CRFMATDRY LOC•'" C L♦ Tr STATE
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<br />Apfel- Butler - Geddes
<br />)2eI FIMFAU HDMF A,V],m IRTAFFT 1111 A F n AKl fJTY nA T.
<br />❑CRAI.RO ❑D°_'_ DannebrQg,t Nebra *ko —
<br />STATE 21P1
<br />L_ 1123.west Second, Grand Island, NE. 68801 _
<br />`
<br />J ANTEDATE CA,,jE 'FNtF4 ONLY ONE CAUSE PER LINE FOP -A. 6, AND lei, 1, N� tMrFM MN, ow.
<br />PART
<br />Cancer of colon with metastasis _ 9 months
<br />PST OTHENSIGN,FICANTCONDITIDNS Ca10•a.R C�riDW�9bM'MFFI OM M,MWM PARTNK FEMALE AAS THEREA�Za AVTOPS X75 WAS CASF REFERRED TC 4FDCAL
<br />PREGNAYCY N THE PAST) 4pNTH$^ I Ex A,AINER OR CORONER'
<br />Small intestional obstruction i ;Aa, ,o.,,, YN [] Ia ❑j Y„ ❑ N� _� No� —
<br />2M 2R, DATE OF MUMMY ,Ab DA, "I 29c HOUR OF HAIRY —x286 DESCRWF HOW I UURY OCCURRED
<br />' 4<oM• � U'IOFM^►R9 M
<br />Svc4 P,nry.I, 120, 1IV,APIY AT WORK i61 %ACE %MUD Y � NRFI!IM I— y„I Will- 1 269 LOCATION STREET GR RI's D no , 1 r OR TOWN STATE
<br />' Honri(b yq„•„ApII YN ❑ Ne ❑ a1Ft CMMr�C. SAFC/1'I i r
<br />2% DATE OF DEATH iW Da Y,I 294 DATE SIGNED 'W a.. Y„ 290 TIME OF DEATH --
<br />r November 5, 1996
<br />270 DATE SIGNED /Ab DIY Yr) 27c TMEE DF DEATH C y PRONOUNCED DEAD M. Ltir -Y,t 290 PRONOUNCED DEAD /MOL.�
<br />November 6, 1996 9:35 a
<br />270 TJ FR oM OF my k . aMn OCC IN tl FM 1F,N. •ro �0" ° 12N sr ONn d F. WiYiI•NIn A,Ia d --
<br />I10wNp9F r rwe,lpAno,I. n my oP+YOII o•AAI occ vna e
<br />P"" N1,1 WINO. \ C M M^I. BAN •ro DIAC• • Ia au• b M C•Whfl FIFI.O
<br />iswll.a.,# •I+a T�,.i S� i F FI+a T�I�F�
<br />1129 do TOBACCO UOE CONTRIBUTE T THE EAT D TISSUE DONATION BEEN CONSIDERED, .200 TYAS CONSENT GRANTED>
<br />❑ YES ❑ NG U UNKNOWN ❑ YES U NO ❑ YES © NO
<br />I
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATORNEY) TvM ff P,ryl
<br />Charles N. Lye, M.D., VA Medi al Center, 2201 N. Broadwell, Grand Island, NE 68803
<br />TEA. REGISTRAR 132V DATE FILED BY REGISTRAR .IMO DA 1 ,
<br />r NOV 12 '�6
<br />
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