|
k i
<br />STATE OF NEBRASKA
<br />t
<br />ljgen
<br />Y��V 1^r
<br />WHEN THIS , COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE ' A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />10/18/2016
<br />LINCOLN, NEBRASKA
<br />DECEDENT -NAME
<br />(b)
<br />(c)
<br />PART
<br />it
<br />DUE TD, OR AS A CONSEQUENCE
<br />THEE SIONIFIC
<br />ACCIDENT,
<br />OR PENDING
<br />T CONDITIONS -Conditions contdbuting to
<br />C)DE, HMNICIIE, UNDET.,
<br />YE STIGATION. (Specify)
<br />FIRST MIDDLE
<br />GEORGE EARL EPP
<br />TE OF INJURY ( ay, Yr.)
<br />201702861
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATHr /e,
<br />StX DATE OF DEATH (Mo., Day, Yr.)
<br />Male' January 16, 1978
<br />2 . 3.
<br />RACE -(e p., White. black, American OWGIN(DESCENT(e.g., Italian, Mexican, AGE -ton R.inhday [ UNDER 1 YEAR UNDER 1 DAY DATE OF GIRTH (Mo -, Day, Yr.)
<br />Indian, .Fc.) (Specify) German, etc.) (Specify) c (Ya.) ( MOS. DAYS HOURS ; MINS.
<br />4 .
<br />White 5. American 6a 54 6b. 6c. 7. April 18. 1923
<br />CITY AND STATE OF BIRTH or not in U.S.A., - CITIZEN Of WHAT COUNTRY MARRIED. NEVER MARRIED NAME OF SPOUSE (If wife, awn maiden name)
<br />ngll.country) WIDOWED, DIVORCED(Speci
<br />Henderson Nebraska 9 U.S.A. in Married 11. Esther Pullman
<br />LAST
<br />S .
<br />SOCIAL SECURITY NUMBER USUAL OCCUPATION (Give kind awed( done during most KIND OF BUSINESS OR INDUSTRY COUNTY OF DEATH
<br />Education 140. Hall. County
<br />of working Ida, even if rNirod)
<br />1 2.508 -26 -0276 13a. School Teacher If, ! 136.
<br />CITY, TOWN OR LOCATION OF DEATH INSIDE CITY UNITS HOSPITAL OR OTHER IN
<br />(Specify Yes or Not give street and number)
<br />1 Grand Island, Nebraskak. Yes 14d. Lutheran
<br />CITY, TOWN OR LOCATION
<br />SIDENCEr STATE COUNTY
<br />15a. Nebraska 15b ball 15c Grand IS1and 15d. 2311 N. Grand Islam' 15..
<br />FATHER- NAME
<br />16.
<br />FIRST MIDDLE LAST 1 MOTHER- MAIDEN NAME FIRST MIDDLE
<br />pENNgR
<br />INFORMANT NAME - RELATIONSHIP MAILING ADDRESS . (STREET on R.F.D. NO., CITY FRS YWN, $T�,TE.�
<br />)
<br />(Yes, no, or %/Armee) '(IT yes, Rive wa and dotes of service)
<br />1BYes/7- 211-44 to 8-1 -46 'firs. Esther Epp- Wife -2311 N Grand Island Ave -Grand Island
<br />BURIAL, CREMATION, REMOVAL . Burial 201..- DATE CEMETERY OR CREMATORY -NAME LOCATION CITY OR TOWN STATE
<br />� Ja.18,1978 Grand Island Cemetery F Grand Island, Nebraska
<br />St�sNAlji ICE SE E NO. FUNERAL HOME -.NAME AND ADDRESS ' (STREET OR R.F.O. NO., CITY OII TOWN, S ZIP) 68801
<br />7 3�1r 4pfel- Butler- Geddes Funeral Home,1123 W.2nd, Grand Island
<br />To the n of my knowledge, d occurred at the time, dab clod nine. nod doe to the On the basis of examination and /or investigation. in onr Maiden dead' scarred at I
<br />.. ca . ),dated. 'Z �', the tier, date and place and doe to the sotne(s) sla
<br />S _ SZ DEATH SIP
<br />is
<br />}"
<br />230.(SlgootureandTitle) '#+ NC 24a.(SignatureclodTufie)
<br />�� DATE SIGNED (Mo., Doy, Yr.) H�JR OF DEATH � M
<br />AO 23b. �xi i
<br />�1 Q J °
<br />f l)/ 7 V 23c. 'r 6. Y+. � M up E 246.
<br />E ° PRONOUNCE DEAD (Mo., Da y, Yr.) PRONOUNCED D 2
<br />EAD (Hour)
<br />a � :
<br />23d. 2 3e. . O Z p m v (M Day NOUNCED , Yr.) DEAD
<br />r / c / 7
<br />* 3 215 A M 214
<br />NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />GERHARDT - -- EPP 1 17 ANNA
<br />WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />s M D. 2444 Faidley
<br />25.
<br />W. J. Land
<br />REGISTRAR M
<br />260.(Sienntxre)' , �
<br />27. DAME' AT USE
<br />PART
<br />(a)
<br />DUE TO, OR AS
<br />SEQUENCE OF:
<br />TER O Y
<br />ER LINE e R (a , (b), AND (c))
<br />bat not related
<br />e
<br />30b.
<br />PLACE Of NJURY At haw*, farm. street, factory,
<br />; *face betiding, Mc: (Specify)
<br />HOUR OF INJURY
<br />30c.
<br />PART III. If FEMALE. WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />Yes 0 No 0
<br />M
<br />304.
<br />STANLEY:, COOPER
<br />ASSISTA M STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />OEUVRE NOW INJURY OCCUNED
<br />STREET OR R.f.D. No.
<br />24c.
<br />C 8
<br />•
<br />STITUTION -Name Of not in either, IF HOSP. Ot INS T. ladscete DOA,
<br />OuipaKeM / EeN r. Rs., Inpotieat (Specify)
<br />Hospital 14.1npatient
<br />STREET AND NUMBER INSIDE CITY LIMITS
<br />(Specify Kes or No)
<br />PRONOUNCED DEAD (Hour)
<br />24e.
<br />/���
<br />�.�lq� { Intmvol b and 4.61h
<br />AUTOPSY WAS CASE REFERRED MEDICAL
<br />(Speei . or No) EXAMINER OR CORONER
<br />(Specify Yee or No) I�
<br />28. 29.
<br />Grand Island, NE 68801
<br />DATE RE __ ED BY REGISTRAR (Ma., Day, Yr.)
<br />I /
<br />T' .{ .O.i:.+F� I
<br />Interval onset and depth
<br />
|