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STATE OF NEBRASKA
<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 />DATE OF ISSUANCE
<br />5/1212017
<br />LINCOLN, NEBRASKA
<br />7 . UAAIEOIATE
<br />PART
<br />I
<br />CreMetien, Removal
<br />March
<br />Burial
<br />20b.
<br />117, 1GNATURE i LICENSE NO.
<br />�±� j 4000
<br />TE OF OEA (Ma.. Dar. Yr.)
<br />3 -4 -88
<br />i.. • �.
<br />(ENTER ONLY ONE C 1 PER UN FOR (a , (b), AND (e))
<br />DATE RECEIVED SY REGISTRAR OAK. Dori Tr,/
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH
<br />CERTIFICATE OF DEATH g a �� 88 03595
<br />DECEDENT - -.NAME FIRST LAST SEX DATE OF OEATi1 Day. 1411
<br />011ietta 2 Female 3 March 4, 1988
<br />RACE -- (roll., Whi Node, Awaican ORIGIN /DESCENT(.. R., Italian.Mix c a. AGE (.... ..44sY UNDER 1 YEAR I UNDER 1 DAY DATEOF*MTN(Mw,OVy Tr.)
<br />Indion,►k. (.440E0) Garnan..IC.)(Sp.eif (V.,) MOS. DAYS HOURS MIWS. 5 1903
<br />r. Shy to s. American Q �I 84 �. Ibe. 7. O c t. s
<br />CITY AND STATE OF BIRTH (N net in U.S.A., CITIZEN OF WHAT COUNTRY MARRIED, NEVER MARRIED, NAME Of SPOUSE (N.7e f .RoJsloe wry)
<br />noon* eouwby) WIDOWED, ED(Sp•cify)
<br />R. Crawford Co., Arkat s s9. U. S . A. f , Mar 1 11. Paul Beckman
<br />SOCIAL SECURITY NUMBER USUAL OCCUPATION (Giro Endof.rork do.. during Nest RIND OF BUSINESS OR MWUSTVtt COUNTY OF DEATH
<br />os.grki.. lil., ewn ifrji d)
<br />) . 446.18 -9024 13a flousewire � 13b Domestic 9, 14 . Hall
<br />CITY, TOWN OR LOCATION OF DEATH INSIDE CITY LIMITS HOSPITAL 01 HER-INS se NSTITUTION -No (N no. in siMar. • NOV. OR MG Mdld... ODA.
<br />O.y.W.yI -. 1... 1.r.d.•I
<br />TA,, Grand Island is Medical Center , (SO.�yI'1
<br />ik 1Yees s ''JJ�� ii'�
<br />or No) 0 drS t and)ly ) `
<br />Ye
<br />IMSIOE:OTT LIMB$
<br />es
<br />26o. (SiR..rrr.)
<br />1.
<br />RESIDENCE -STATE COUNTY CITY, TOWN OR LOCATI
<br />Is 1s t,. Hall 1 15 e Grand Island
<br />MIDDLE T MOTHER- MAIDEN
<br />16.
<br />WAS DE CEASED EVER 1N U.S. ARMED FORCES?
<br />(T.., .o. .nk) ((H )N. R iw .e and darn of .c erise .
<br />1B. No 1 1
<br />DUNAL;:.
<br />B
<br />23a.
<br />i
<br />Richard Meadows
<br />W. L. Fowles M.D.
<br />8, 1988
<br />DATE SIGNED (Mo.. Day, Tv.)
<br />3 -9 -88
<br />)3b.
<br />To Dko b.0 of s.y Wwd.dR.. deaf+..
<br />mods) MAW.
<br />29d.(S .+.. .ad Tid.) Br
<br />NAME AND. ADDRESS OF CERTIFIER (PHYSICIAN, CO
<br />201703351
<br />BUREAU OF VITAL STATISTICS
<br />MIDDLE
<br />Mae Beckman
<br />INFORMANT- NAME - RELATIONSHIP - MAILING ADDRESS (STREET ORRf.D NO.. CITY OR SATE ZIP)
<br />19 Paul Beckman-Husband-312 S. Walnut - Grant. isiaga,°ItE
<br />CEMETERY 01 CREMATORY -NAME LOCATION CITY OR TOWN STATE
<br />20,. Grand Island Cemetery xi& Grand Island, NE.
<br />FUNERAL HOME -NAME AND ADDRESS (STREET OR Lf.O .W.. CITY OR TOWN. SIAM LT)
<br />21Apfel -Butler -Geddes 1123 W. 2nd, Grand Island, N8.', 6
<br />DATE SIGNED (Me. Otto, Tr.) HOUR OF DEATH
<br />HOUR OF DEATH
<br />2:50 P.M.
<br />d.. to Ow
<br />1 � AC � O , NSSEQ , UENCE �y/� �(
<br />4,) IJE/1.v V V"A o/ !` `k.' rA� "_ 'A
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />17.
<br />STANLEY COOPER
<br />ASSISTA STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STREET AND NUMBER
<br />1Sd 312 S. Walnut
<br />ELS PHYSICIAN OR COUNTY ATTORNEY) (Typ. or Print)
<br />716 Alpha St. Grand Island, NE. 68803
<br />Nancy Jane Jackson
<br />..i t
<br />1 .13 24o. 24b.
<br />s t < PRONOUNCED DEAD : PRONOUN CED DEAD f(iwr)
<br />, (Mo., Day. Yr.)
<br />u r g i t g 24e. 24d. A E O 0. AMP basis .1 ar :.
<br />.iwa�t...44 InnsiiRof JUL ... • 646 d.rf►..c.n.d:ot
<br />tA
<br />• a' . ho., dos. and plaice r. ce ..d d lk• aan(d .Teal.
<br />~ v 24s. (Sis.M...wed now ►
<br />off 01111 SIGNIFICANT CONDMONS- Caditi.., c.nhi►.ting to deo* k.t.....1.l.d
<br />ACOOENT, SUICIDE. HOMICIDE, UNOET.,
<br />.i,:.:. ea spacw0: NiAHSTIDAT10N. 45a.4)
<br />3044
<br />'MIN AT W
<br />OATS Of INJURY (M.., 0.y, Yr.)
<br />30
<br />tad.ry.
<br />.Itb b.ildi... so. (Sp. 314)
<br />301.
<br />PART DLit FOWL. WAS THERE A
<br />N EOPAANCY 1Nly UR MSLT MONTHS?
<br />Y. 0 A�
<br />HOUR Of INWIY
<br />30t
<br />I /!CARON
<br />DOCRRJE NOW • JURY OCCUSIO
<br />30d.
<br />STREET OR LF.Q NL
<br />
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