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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, <br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />201'03068 <br />3/24/2017 <br />DATE OF ISSUANCE <br />LINCOLN, NEBRASKA <br />Amended <br />MTh OF1 LY A- DIPALIRENT OF HEALTH MC s SERV SANDSUPPORT <br />December 21, 2000 <br />6 :reii' ADD tOCEOF SPIN /aa7eUSA aMV A TA <br />Fairfax, Missouri <br />leGtRa# ae.E. <br />S06 -24 -8609 <br />Mi FACaUtY • Duro - ._ li seaf lkamt paateaaet <br />Hamilton Manor <br />tm tcwlitxai�cTe�+oF Trc <br />Aurora <br />Nebraska <br />>c RAC£ <aa;,wlr.. Crd N6aN C+1aa6. <br />kite <br />TN WAAL O($,10011 Aiv6■110Al'9dro4mea1 MOW ILAINESS INDUSTRY <br />arattettli oat /tare. D 1yvj�c{tjj ciEha d.ry 10 -121 06166. :rlos -i <br />retired laborer Industrial (factory) <br />K FATNEE1 -NASIE <br />MST <br />SAM. TADI <br />ASFP 094 ar U.S. mow FORCES? <br />IAoeArM.M ( M vat awe vow a6d owes d swami <br />Yes I <br />1!0 EeYIOiAAR 1r661113A0ORESS <br />P.O. 564 Cti. ro, NE 68824 <br />F 6 <br />326. PJ0036PI <br />Funeral Home ❑ Ge- ❑ <br />2,¢t <br />FUNERAL NOME ADDRESS /SWEET OR RF.D. ND. COY OR TOW. . STATE. 2J' <br />P.O. Box ` 126 Wood River NT 3 <br />T <br />Charles <br />1► A CONSECeUENCE OF <br />i s <br />Hall <br />VTma.sum rncs <br />CERTIFICATE OF DEAD-; <br />ANDOLE LAST 2 SEA <br />Edward Simpson Male <br />Cairo <br />T,. 11.1 EST1aY let. 1 ttinNiLL Ott * ❑ISIDOOED i,3 WANE OF SPOUSE .;/e! anormadFn Maar <br />American ❑+ ❑ trecettly lacicner `Filer <br />15 EDUCATION 1&f[fy ant 6Q661 Dade <br />aaCCLE LAST - 17 910T143i <br />William Sin so <br />it. PAORNioNT - AuMAaE <br />E tbilt,ethy sin son <br />10«et t 011 .13 Ti6_WI OR TOWN. STATE. 73R1 <br />7010EtiAtE CYISF TENTER ONLY ONE CAUSE PER UFE FOP A. 11$ AND MI <br />PART ./ r 1- <br />a> '� - •' <br />. ' . 0--,j I vL _s-1n- G.-nt` —> 'k. -i t . rQ. <br />DIIETO. .. OF l <br />• <br />- 'PART N E FEMALE, WAS - MERE A 21 AUTOPSY <br />PREGNANCY M THE PAST 3 MONTHS" <br />;owes 10.5,1 YRS n No Fl Yea n No <br />CONEFTCNIS . OTAldemr wlaEAa9 @ Pr clelh PS TEA Mind <br />i S utLIZS te. <br />2A. +:' I Mb DATE OE ODU Y ANC Day. riJ 12CA HOUR OF INJURY : 26d. <br />C A zTOr6 L_I Unspiwneea0 <br />SvRla Penkaq 1 ae 4JUPY AT WCIR11 29I PLAC' <br />.67.6 10 a Yea ❑ Nd ❑ oer.'e <br />276 DATE DE OFJATN left Day F/./ <br />1 Sit I 0 C <br />275 DATE SIGNED Ae, Dry Y. 27, TIME OF CEATH <br />g (2 I /C:C) 0 130 M <br />� �d ,aa»t�Aleamy . • . .. 1 ��� da�� plane <br />ORMAN ROW. 'r+.letta[ alas Tft <br />2i Olfi TOBACCO USE 03BrieIBUTE TN? 30.3 HAS 0,16.01 <br />AND <br />YES <br />❑Ne <br />Jeff <br />oem: <br />M <br />Be . *OE - rA etes. LOWER 1 YEAR LJCEA 1 DAY <br />RYA 72 Sa NIDS a DAYS - 5C 06XII6 aAINs <br />ER PLA1 OF DEATH <br />tfpNPRAL ❑ q;e�aeA <br />r: H1 Lrmsw <br />1-...,! 9C�A <br />arm. Ern* Tammy <br />YES <br />I <br />SS OF CERTIFIER NYSPCOAN. CONONER S PHYSICIAN OR COUNTY ATORREY> 7Tjpe <br />FIRST <br />Ruby <br />STANLEY COOPER <br />ASSISTA STATE REGISTRAR <br />DEPARTMENT HEALTH AND <br />HUMAN SERVICES <br />OIlEN NAr6R. Hare <br />ResAance <br />❑ Ch dd.* <br />AS .6.1,11E CM Lois ads COM •5 OF DEATH <br />Yea No Hamilton <br />x r TORT. ORL0D*T .a <br />eON Tao STREET MO A 'Aft I9t ASE* an. awns <br />Yes X he 0 <br />1 P.O. Box 564 <br />EM <br />215. DATE 21, CEMETERY OR CREMATORY NME <br />a ❑ R 12/2/2000 Mt. Pleasant Cemetery <br />210. CETAETeiT OR CREMATORY LOCATION CITY Y 5 Y OR TO STATE <br />SCRIBE HOW MAJ'RY OCCARaR® <br />req. . LOCATION STREET OR P F 0 NO <br />2N: Da PORED Ain Dar <br />w <br />r.. F, <br />2E PROACYINCED DEAD Ab DI <br />VITAL <br />ffiul <br />3. DATE OF DEATH Monet Div it/N1 <br />November 28, 2000 <br />6. DATE OF MO. Aldan Dawign <br />December -; <br />NACB+StRiNANE <br />Gardner <br />Cairo, Imo <br />CaTY OR TOWN <br />AR TAR OF DEATH <br />3DD WAS CONSENT GRANTED <br />❑ YES CK NO <br />Aft.. Day FL; <br />kiervai Nraarl drag am amyl <br />/ e.rw1E �.Nl aeam <br />4. <br />acienW awr/.1 .AI W7 and dean <br />25 WAS CASE REFS TU NEOICAL. .. <br />EXAMEN OFKO ONEN <br />SEA PRONOUNCED DEAD /b.. <br />tad. On BE Nara S warren een and a ++magn.^. n a7 oPeon aN n accewae at <br />7r rM: dar art piaoa ann due Oat t ea:aNN ford <br />'SEAT Me and INN I► <br />DONATION BEEN CONSVE EEr <br />C) <br />N.) <br />CA) <br />CO <br />(..t) <br />C <br />