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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANDS
<br />__iQCES
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL R%'MDVN-FK.->z ➢YITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISftt&ft p", Wh=f--jS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE 200005169
<br />JUN 1 2000 J�INCEYS:c9OPeRs
<br />ASSl lAAW STATE REG/STRAI#=
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN S E4�4tySTEIW
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OFVITAL STATISTCS. % $ 13885
<br />ri a 1
<br />CERTIFICATE, OF. .'DEATH t. (r. ,7-
<br />DECEDENT NAME ,:, FIRST MIDDLE U ATE D A H (Moll Day, Yr.)
<br />4 GESINA� ICOANNA GRAF Fe�mme� Deeemben 19 1978
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<br />a :- . NAME OF SPOUSE (// , gjw hoiden none)$
<br />�CI AND S ATE Of BIRTH (N not in U S-A C1T12EN OF WHAT COUNTRY MARRIED NEVER MARRIED
<br />W! -:_
<br />TiM% •a , WIDOWED DI ED( p•ci(y)
<br />or�Zcphan, : Nebu ska U:S. A. W ido`wed�
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<br />Owp•N•n1/E.•r. Bel.. In pebMl(sp «ayJ
<br />14.. 1 np a.tient
<br />MESIOENCE STATE COUNTY CITY, TOWN OR LOCATION STREET AND NUMBER INSIDE CITY LIMITS
<br />r' (Sp•ciy Yoe o No)
<br />sa r Nebnaaka ` Tbb. NQ,� ISc. r ' l 1Sd. Unkn wn Is., I7/
<br />A 3 R NAME 1 T MIDDLE CAST MOTHER -MAIDEN NAM FIRST MI LE LAST
<br />C ltw' Rewen1, s Anna - - - -- Mennen
<br />WAS DECEASED EVER IN u S. ARMED FORCES? INFORMANT - NAME - RELATIONSHIP- MAILING ADDRESS (STREET oR R.r.D. NO CITY OR TOWN, STATE. ZIP)
<br />s� (YM, +M er Ynk) IN yes give .rot oral dabs of so-k•l -
<br />Ts x$ I No �° -- - :` ►, {n. Gondon Gna - GA=dbon- Donip(tan, Nebh."ka 68832
<br />s; BURIAL,. Cremation R•mowl DAT Dec n CEMETERY OR CREMATORY -NAME LOCATION CITY OR TOWN STATE
<br />Y BUh,CQ,P lob. 1978 . 20c. Cedars View Ceme god. Don i' han Nebnaaka
<br />EMBALMER, SIGNATURE 6 LICENSE NO ay30 FUNERAL HOME -NAME AND ADDRESS (STREET OR R.r.D. NO., CITY OR TOWN, STATE, ZIP)
<br />' e = en- eddes 1123 W. 2nd Gnand I.6tand' NE. 68801
<br />t1vN� • b•M at w WI•wl•dye, d erred •1 tM N•.• b and p • d •• ro Ih• - .: On th. boot of •to. ;-t;M end /er inv.t{yaKM, in w o nron death occurred a
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<br />2 (t "'. 'David Cohan A(eD. 729 N. Cwste�c Gn d I�tand NF 6880
<br />REGISTRAR i- - DAT ECfIVED BY REGISTRAR (Moe, Day, Yr.)
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANDS
<br />__iQCES
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL R%'MDVN-FK.->z ➢YITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISftt&ft p", Wh=f--jS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE 200005169
<br />JUN 1 2000 J�INCEYS:c9OPeRs
<br />ASSl lAAW STATE REG/STRAI#=
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN S E4�4tySTEIW
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OFVITAL STATISTCS. % $ 13885
<br />ri a 1
<br />CERTIFICATE, OF. .'DEATH t. (r. ,7-
<br />DECEDENT NAME ,:, FIRST MIDDLE U ATE D A H (Moll Day, Yr.)
<br />4 GESINA� ICOANNA GRAF Fe�mme� Deeemben 19 1978
<br />RACE (• g., While, Black, Aw•rken ORIGIN /DESCENT(•.g., Italian, M• :icon AGE -trot Binwey UNDER i YEAR 1 UNDER 1 DAY DATE Of BIRTH (Moe, Day, Yr.)
<br />V )nt+lAn • ($ r1).j - G.rnwn )(Sp «iIy) (free) - MOS DAYS HOURS RUNS,
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<br />a :- . NAME OF SPOUSE (// , gjw hoiden none)$
<br />�CI AND S ATE Of BIRTH (N not in U S-A C1T12EN OF WHAT COUNTRY MARRIED NEVER MARRIED
<br />W! -:_
<br />TiM% •a , WIDOWED DI ED( p•ci(y)
<br />or�Zcphan, : Nebu ska U:S. A. W ido`wed�
<br />. s.: 9
<br />,t SOCIAL SECURITY NUMBER
<br />11
<br />USL'4L OCCUPATION (G iv* kind of work doom during most
<br />eFwerkinp li ewo if rot
<br />KIND Of BUSINESS OR INDUSTRY
<br />DEATH
<br />13a. owsew.c e v
<br />/3b. Dome�S�.te
<br />ZCOUFJTYC;
<br />Hct.P,2
<br />TOWN .Oft LOCATION OF DEATH
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<br />INSIDE CITY LIMITS
<br />HOSPITAL OR OTHER INSTITUTION- Name (If not in either,
<br />IF NOS►. OR tNST. 1•dkeb DOA,
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<br />ive sire on nvlob•r ' - -' -.. -
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<br />Owp•N•n1/E.•r. Bel.. In pebMl(sp «ayJ
<br />14.. 1 np a.tient
<br />MESIOENCE STATE COUNTY CITY, TOWN OR LOCATION STREET AND NUMBER INSIDE CITY LIMITS
<br />r' (Sp•ciy Yoe o No)
<br />sa r Nebnaaka ` Tbb. NQ,� ISc. r ' l 1Sd. Unkn wn Is., I7/
<br />A 3 R NAME 1 T MIDDLE CAST MOTHER -MAIDEN NAM FIRST MI LE LAST
<br />C ltw' Rewen1, s Anna - - - -- Mennen
<br />WAS DECEASED EVER IN u S. ARMED FORCES? INFORMANT - NAME - RELATIONSHIP- MAILING ADDRESS (STREET oR R.r.D. NO CITY OR TOWN, STATE. ZIP)
<br />s� (YM, +M er Ynk) IN yes give .rot oral dabs of so-k•l -
<br />Ts x$ I No �° -- - :` ►, {n. Gondon Gna - GA=dbon- Donip(tan, Nebh."ka 68832
<br />s; BURIAL,. Cremation R•mowl DAT Dec n CEMETERY OR CREMATORY -NAME LOCATION CITY OR TOWN STATE
<br />Y BUh,CQ,P lob. 1978 . 20c. Cedars View Ceme god. Don i' han Nebnaaka
<br />EMBALMER, SIGNATURE 6 LICENSE NO ay30 FUNERAL HOME -NAME AND ADDRESS (STREET OR R.r.D. NO., CITY OR TOWN, STATE, ZIP)
<br />' e = en- eddes 1123 W. 2nd Gnand I.6tand' NE. 68801
<br />t1vN� • b•M at w WI•wl•dye, d erred •1 tM N•.• b and p • d •• ro Ih• - .: On th. boot of •to. ;-t;M end /er inv.t{yaKM, in w o nron death occurred a
<br />` �`' t•"s�ti oO ,� _� �. Z >' /h• tie.e, dal• end ploc•r a..d dae b M• cae.•(t) trot d. P'
<br />1, :230 (S.ynsevn end iiN•1 • ... - /h ) -
<br />h C 240. (SJ.narvr• and Tio.) �
<br />•s E
<br />r , ;. DATE SIGNED (Moe, Day, Yr,) HOUR OF DEATH a =t Mo. r.) DEATH
<br />u `23b 2. 2 I
<br />23c. M t 4b. 24c. M
<br />DATE OF DEATH (Mo., Day, Yr.) -0 PRONOUNCED DEAD PRONOUNCED DEAD (Hour)
<br />"r`
<br />z<
<br />b (Mo., Day, Yr.)
<br />�29 �_
<br />3d 119 124d. . ?fit- ... _.... - -_ _
<br />� nAewe A)iD AD13wESa F CEIi7iiiElT ((PHYSICIAN, CVkGMCIC$ PHYSICIAN CM COUNTT A1fORNEY) (type or ►nnl) M
<br />2 (t "'. 'David Cohan A(eD. 729 N. Cwste�c Gn d I�tand NF 6880
<br />REGISTRAR i- - DAT ECfIVED BY REGISTRAR (Moe, Day, Yr.)
<br />2do7rro..et �)
<br />i
<br />27. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (c)) Inbrwl beMM --.of acid death
<br />►ART t
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<br />i _f r.ai.S NVCI\ - �( / /�iJ /L�S -�Cl 'I / P� f•��i: �s
<br />wl�iii f7it�e .e
<br />I-f—I bet .een onset o..d death
<br />DUE TO, OR ASS o CONSEQUENCE OF; len,el be I d d
<br />- - In Me Mto on eoth
<br />PART. H!R SIGNIFICANT CONDITIONS — CMd'niem centnbetiny b deolh 6.f not totaled PART III. It FEMALE, WAS THERE A AUTOPSY WAS CASE REIERRED TO MEDICAL
<br />I) r�E PREGNANCY IN THE PAST 3 MONTHS? (SpeoI, EXAMINER OR CORONER
<br />Aw ✓_ (Specify Ye. e. No)
<br />/ Yee (] No 78.. ✓ 29.
<br />g:
<br />ACCIDENT. SUICIDE, HOAMCIDI, UNDET., GATE C INJURY (M.., Dap Yr.) NOUR Of INJURY DESCRIBE NOW INJURY OCCURRED
<br />Of PENDING INVESTIGATION. (Speofyj -
<br />30b. 30c. M ' ' 30d.
<br />INJURY AT WORK - PLACE 'Y INJURY Al he— Iore. woot, loctory
<br />a*(S Ye•w No)� •Ilk• ►wild nq •k (Spec fy/ D. No. OR TOWN A,
<br />LOCATION - STREET OR R P.
<br />ak +R`.ta'Iiz '
<br />ST AI
<br />Recorder's Memo: The North Half of the Southeast Quarter (NMSE1 /,)
<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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