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WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AN04 RAiJA7VT'`ERWCES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL FWF=R&dV -0 :E WH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS_J�ft_S_ �_ &p", Wft0 is
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DAT F ISS
<br />�I V N 1 L �d
<br />200005168 ASSN IAN STATE REG STRA1
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICE&4YSMV
<br />' No
<br />STATE OF NIEBRASKA- DEPARTMENT OF HEALTH
<br />Buma11 of vita Statistics r- 72 10858 -1
<br />CER TIREATE OF DEATH A
<br />It-It TD( NUMf1D
<br />RaASEO -NAME PeDST NTOOU LAu S
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<br />rnr•T
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<br />! , e !
<br />! 9-21-72
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<br />WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AN04 RAiJA7VT'`ERWCES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL FWF=R&dV -0 :E WH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS_J�ft_S_ �_ &p", Wft0 is
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DAT F ISS
<br />�I V N 1 L �d
<br />200005168 ASSN IAN STATE REG STRA1
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICE&4YSMV
<br />' No
<br />STATE OF NIEBRASKA- DEPARTMENT OF HEALTH
<br />Buma11 of vita Statistics r- 72 10858 -1
<br />CER TIREATE OF DEATH A
<br />It-It TD( NUMf1D
<br />RaASEO -NAME PeDST NTOOU LAu S
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<br />rnr•T
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<br />! , e !
<br />! 9-21-72
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<br />"As D
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<br />Cn
<br />DATE Of BIRTH t.owrN, o^,, C
<br />COUNTY Of DEATH
<br />�
<br />CD
<br />p
<br />M
<br />set. I $"CMT I IMR"I"T ( IRAN I
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<br />k. f
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<br />CITY, TOWN, DA LOCATION Of DEATH w
<br />w66w Crew LMNA N
<br />NOSPITAI OR OTHER BrSTTMK)PN -NAME 1 N NOT IN to"e, Gnt svestt A
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<br />AND NuMDt11
<br />-1 Aln3rj T 1I. K
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<br />STATE Of BIRTH t w Not w D.S.A.. 14AMIS C
<br />Fri
<br />MARRIED, NEVER MARRIED. S
<br />St1RYIV04G SPOUSE I w -wt. Gres MA101IN NAme I
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<br />70
<br />WIDOW®, ONORCED t s►ecln I
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<br />M. �. 1
<br />11. Waddin on
<br />SOCIAI U
<br />USUAL OCCUPATION IOM came or worm Dome ounNG moot, of K
<br />KID Of BUSINESS OR INDUSTRY
<br />WCMrtD10 LIIe. fM H M arium 1
<br />11.506 44 2 1
<br />11.. gut 1
<br />17b F
<br />RESIDENCE -STAFF C
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<br />C�
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<br />to
<br />1>D 'Irq. Arlene Qraf Wiff, lir, Doni han Nebr. 68832
<br />PART 1. DEATH WAS CAUSED BY: jffM* ONLY ONE CAUSE PER 1614 FCa (a), (b), AND (,)i ♦
<br />♦ 11W /N AL
<br />M r- rYolit CADSI "
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<br />CONDITIONS, N AM,
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<br />. T
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<br />Ib
<br />M 01Ur91
<br />ACCIDENT, SUICOE, HOMl�E. -
<br />-" - -MV t LtONtx. DAT, TtAr I H
<br />HOW INJRY OCCURRED t t.IrYe ..wrl.w M TNw .eye PAM I M PART D, Rt.A I I a "
<br />OR UNDETERMINED IWKIFYY �
<br />�
<br />�-
<br />INJURY AT WORK P
<br />PLACE OF 04MY At NO-f, FARM, ITINY. FACTORY, L
<br />1 SPICIFT of Oa "a) O
<br />�'
<br />- _
<br />-�
<br />!M. •�— �
<br />►-'
<br />CERTIFICATION -- MONTH LAY "AD MONTN DAY v1M A
<br />AND LAST SAW NIM /9118 A71Vt CO. 1
<br />1 WD /6.0.01. lfv 1914 O
<br />i1
<br />PIIYSWIA041N�o 1111 TO M
<br />MONTH DAY nAa 8
<br />80066 A"" 01.,91, C
<br />C Am, AND. t0 1"I "$I
<br />!If wa♦u0 Feq- I— !1►. �! l
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<br />CEI WKATWN- MEDK:AL EXAMINER CORONER: ON TTN "&IS of M "OUR or D1At" MoD I01NT WAS MONOU"CID DIAD
<br />ErYINANON OF TNf 11091 AND /OS TM INVISTIO♦TION, IN MY OPINION, - rONT91 DAY nAt NOW
<br />D1ATN O<CVW" ON IM 01A11 AND 041 TO 101 CAVIIIST s1A1T0.
<br />"0 M. M. M.
<br />CIRT1f1ER —NAME trim OD Pfwn - A e
<br />eet not A 0 INONTN, DAY, vwl
<br />CD
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<br />C ERY OR CREMATORY —NAME 10CAT10►4 CIn be TOWN sun
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<br />l :1. p1 QBTttPtr3T N.. DOt11 han Nebr.
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<br />FUNERAL HOME -NAME AND ADDRESS I STntT w L.P.D. No., CITY ON ToWN, sun, t,M I
<br />-
<br />No ?2 P
<br />P- 1- t eddes 2nd &_Wasbjngton,rrAnd TG1and_ Nebr. 68801
<br />WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AN04 RAiJA7VT'`ERWCES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL FWF=R&dV -0 :E WH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS_J�ft_S_ �_ &p", Wft0 is
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DAT F ISS
<br />�I V N 1 L �d
<br />200005168 ASSN IAN STATE REG STRA1
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICE&4YSMV
<br />' No
<br />STATE OF NIEBRASKA- DEPARTMENT OF HEALTH
<br />Buma11 of vita Statistics r- 72 10858 -1
<br />CER TIREATE OF DEATH A
<br />It-It TD( NUMf1D
<br />RaASEO -NAME PeDST NTOOU LAu S
<br />SEX D
<br />DATE Of DEATH 1 MONTH, DAY, VIA@ I
<br />elder s
<br />!
<br />De Wavne e
<br />! , e !
<br />! 9-21-72
<br />RACE votior , NfOao. *w4DwAN INDIAN;" AGE -LAfT - I
<br />IIT101a t "
<br />"As D
<br />D♦ra 1 D
<br />DAY D
<br />DATE Of BIRTH t.owrN, o^,, C
<br />COUNTY Of DEATH
<br />I MOa: D
<br />DAB' T
<br />TIOIMf -
<br />-w. e
<br />set. I $"CMT I IMR"I"T ( IRAN I
<br />ew.AD 1
<br />f i
<br />A. k
<br />k. f
<br />f. i
<br />its. Han
<br />CITY, TOWN, DA LOCATION Of DEATH w
<br />w66w Crew LMNA N
<br />NOSPITAI OR OTHER BrSTTMK)PN -NAME 1 N NOT IN to"e, Gnt svestt A
<br />fPecwT VIS Oa No
<br />AND NuMDt11
<br />-1 Aln3rj T 1I. K
<br />K.
<br />STATE Of BIRTH t w Not w D.S.A.. 14AMIS C
<br />CITUMN Of MIINT OUF Y M
<br />MARRIED, NEVER MARRIED. S
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<br />f M
<br />M. �. 1
<br />11. Waddin on
<br />SOCIAI U
<br />USUAL OCCUPATION IOM came or worm Dome ounNG moot, of K
<br />KID Of BUSINESS OR INDUSTRY
<br />WCMrtD10 LIIe. fM H M arium 1
<br />11.506 44 2 1
<br />11.. gut 1
<br />17b F
<br />RESIDENCE -STAFF C
<br />CCANM C
<br />CRY, TOWN. OR LOCATION w
<br />wfwt Cm kwmns S
<br />STREEr AND Pi =
<br />I SMCI" T1S OD Nor
<br />/110_ I
<br />I4k 1 I
<br />ILA. 1
<br />1 {
<br />{p.
<br />FATHER —NAME Fnft mom MOTHER —
<br />—MAMEN NAME Flest -IDOtt ufr
<br />Gesina -- Rewer}„s
<br />INPORFI{/LNT -r NAME- RELAFNDNSNM MAKING ADDRESS MIRIT Of t...o. NO., CRY ^t'0", STAII, ZVI
<br />1>D 'Irq. Arlene Qraf Wiff, lir, Doni han Nebr. 68832
<br />PART 1. DEATH WAS CAUSED BY: jffM* ONLY ONE CAUSE PER 1614 FCa (a), (b), AND (,)i ♦
<br />♦ 11W /N AL
<br />M r- rYolit CADSI "
<br />C 1 � � r 7
<br />Iry
<br />CONDITIONS, N AM,
<br />WNICN D
<br />DAVI DIM TO (
<br />tTINO CADff LAft
<br />(�(
<br />PART N. OTHER SKPWICANI CONDITION& CON"T1p01 CONTWUTNq TO OfATH OUT NOT "LATED P
<br />PART RI. n FIMALE, WAS THIN A A
<br />AUTOPSY I
<br />IF YES Wttt r1.01.0s ca+•
<br />TO CAPS! GIVEN IN PART %sp P
<br />PREONAHCT W '"I PAST S MIONTNST t
<br />t Its W NOI 6
<br />66018101 IN D4114MININO CAVU
<br />. T
<br />TES 0 NO 0 M
<br />Ib
<br />M 01Ur91
<br />ACCIDENT, SUICOE, HOMl�E. -
<br />-" - -MV t LtONtx. DAT, TtAr I H
<br />HOW INJRY OCCURRED t t.IrYe ..wrl.w M TNw .eye PAM I M PART D, Rt.A I I a "
<br />OR UNDETERMINED IWKIFYY �
<br />�
<br />�-
<br />INJURY AT WORK P
<br />PLACE OF 04MY At NO-f, FARM, ITINY. FACTORY, L
<br />1 SPICIFT of Oa "a) O
<br />OPFTCt MDO ,FTC.
<br />- _
<br />Rlt. e_ !
<br />!M. •�— �
<br />�. ��_ -
<br />CERTIFICATION -- MONTH LAY "AD MONTN DAY v1M A
<br />AND LAST SAW NIM /9118 A71Vt CO. 1
<br />1 WD /6.0.01. lfv 1914 O
<br />OE At" OCCVMD At "to PT.Ats, ON not
<br />PIIYSWIA041N�o 1111 TO M
<br />MONTH DAY nAa 8
<br />80066 A"" 01.,91, C
<br />C Am, AND. t0 1"I "$I
<br />!If wa♦u0 Feq- I— !1►. �! l
<br />llt. - -
<br />lid. 7.(? -'Y !
<br />!M._ -[M. O weRt;ow ttO
<br />CEI WKATWN- MEDK:AL EXAMINER CORONER: ON TTN "&IS of M "OUR or D1At" MoD I01NT WAS MONOU"CID DIAD
<br />ErYINANON OF TNf 11091 AND /OS TM INVISTIO♦TION, IN MY OPINION, - rONT91 DAY nAt NOW
<br />D1ATN O<CVW" ON IM 01A11 AND 041 TO 101 CAVIIIST s1A1T0.
<br />"0 M. M. M.
<br />CIRT1f1ER —NAME trim OD Pfwn - A e
<br />eet not A 0 INONTN, DAY, vwl
<br />MAl1LItG ADDRESS- CERTIfLpR 1TrtT ON I.r.o. No. 08 STAN - 1.01
<br />!>r. 7 u4 W, 2n T
<br />SWAL, CREMATION, REMOVAL C
<br />C ERY OR CREMATORY —NAME 10CAT10►4 CIn be TOWN sun
<br />I fnaFY ,
<br />!a r,1i1? l
<br />l :1. p1 QBTttPtr3T N.. DOt11 han Nebr.
<br />I
<br />FA-ft 1MOTerN, "T, "ART F
<br />FUNERAL HOME -NAME AND ADDRESS I STntT w L.P.D. No., CITY ON ToWN, sun, t,M I
<br />-
<br />No ?2 P
<br />P- 1- t eddes 2nd &_Wasbjngton,rrAnd TG1and_ Nebr. 68801
<br />Ilk.
<br />REGISTRAR -StGNq
<br />a!o Ista�A.J
<br />Recorder's Memo: The North Half of the Southeast Quarter (N%SE!4)
<br />of Section Fourteen (14), in Township Nine (9) North, Range Ten
<br />(10), West of the 6th P.M. in Hall County, Nebraska
<br />
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