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<br />20010504'7
<br />Rev 1197
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<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />VITAL STATISTICS
<br />-- - --
<br />CERTIFICATE OF DEATH
<br />UEr_EI ENI -NAME -- FIRST MIDD(E LAST _ - -- SEX 2
<br />2 SEX l DATE OF MATH AM
<br />Gerald Kent Fahrenbruch Male November 2, 2000
<br />4 f;IIf AID STATE (f DIIIIH andbU54 - - -- —
<br />r name ca,rHryl 5a AGE LaM BIrI1gpY UNDER 1 YEAR UNDER I DAY 6 DATE r,1 HPNH
<br />aJ,l
<br />Holdrege, Nebraska "' �M$? DAY$ xFloDgs -MN$
<br />53 __`____ June 17, 1947
<br />I SOr, aI SECUR11Y NUMOFR -. -- - 88 PI ACE OF E TH ___
<br />MOER
<br />HOSPITAL M ❑ Nursrrrg HDr.M
<br />_ 505 -60 -3872 IrrPalr.
<br />M fAI:e ITV Name - - - - -I #elf rr 11.1A». give snrvHam mmrpevl ® EROMDNreM ❑
<br />Peavlerve
<br />St. Francis Medical Center ❑ 1— ❑ l 1n1ISPp I
<br />8l (.Ilv TOWN OII(N.At -N 1 U61N--- - - - - -- BU INSIpE C17Y UM11$ Be COUNTY Of DEATH - — " -- - '-
<br />Grand Island .a U ND El Hall
<br />9a NI SII E5 TE 9b COIlNTY _ - - -- 9c CITY ,TOWN OR I.00RIX)N - -- BD $THEFT ANp NVMRFf lAI[ fvp7rp DrrNl 9e IN5lUEf1
<br />Nebraska Hall — rand Island_ 2426 Wicklow Drive 6880
<br />UI NArF y W eBla Anw,r n TI ANCF$IRYIeg Mal an. Merr,can Germsn. etcl ----- " - - - -- - -��
<br />Ig (y-I MARRIEp [] WIUOWFD I] NAME Of SPOUSE rM xne P•vs maden ,.ar.rr
<br />elr 1 NI ISDer ryl _
<br />_ White American �NEYFII _ �DY( 1(:ED
<br />MHN Diane Schuppan
<br />1 e IISUAI (X'Cl V 1 " II C — -- -- ARD
<br />Frgdrwaa dvM Mrrr,g mr,sl lap KIND OF BUSINESS INDUSTRY T -- - - --' - -- --
<br />dar EDUCATION IS vY ngMNprane cn,r Db rll
<br />___ Salesman Retail Paper Sales L E" "a12s °^ rrlolal CMe41I
<br />16 [AIOER NAMF TID$I - -- - MIDUIE IAST - - -- I> MOWER FIRST MIDDIE -- MAIDEN SOHNAME -
<br />_ _ Al_fred Fahrenbruch Emma Sitzman
<br />IS WnS DE('.E ASFD E_ VEN III U S An C, FORCESD _ —__ RMA
<br />19a INfONI NAMF. -
<br />IYes , ur u„ I III yes prvl• war erq pales ul serncesl
<br />y
<br />_ Yes Dates Unkn_o_w_n Diane Fahrenbruch
<br />M
<br />19b INIOHANI MAl11NG ADONF SS ISIHEETORRFD NO. CITYORT(IWN SIATE - --
<br />2426 Wicklow Drive, Grand Island, NE 68801
<br />ZU FMIIAI MFR.SI(iNA NIRf AIIf,ENSE NO 21e METHOD OE D$POSN TUN 21p DA IE i1T CEME IERY OR CRf MAIURV NAME
<br />Not embalmed ❑Bpr• []HampYal Nov. 3, 2000 Central NE Cremation Svc.
<br />] ?a IIINF.NAI NOME NAME - - - -— 2Mtl CEMETERYORCRFMAIURY LOCAUON
<br />Livin stop- Sondermann F.H. EXI0 _ []D° " " °'
<br />?N. IIINk DaI 1TOME ADUfII SS IS . G- -ib- bon Nebraska
<br />I
<br />601 North Webb Road, Grand Island, Nebraska 68803 - 4050__
<br />�PIII IMMFUTAIE CAIISF IENIERONLYDNECA (15EPEn(INEFORIAIIb1ANDlc11 MarvM beNrrwr tinsel a•I
<br />_ i1/T r utcAil_. rQ �u �jr u.tJ �1pY.�Y
<br />Wt IO ON AS A CONSFOIIENCE Of
<br />IN .i��YSl GV !u
<br />11 S iY1i yun�
<br />DUF 10 OR AS A CONSFOIJFNCE " -- '- — --- - - - - -_
<br />InM,rral Mlwaen on ..r ., ,
<br />Irl
<br />PANT w4c, SGNIF CANT CONDITIONS,DMgrl DnscpMrrgMrrgblM peaM put rld raMMJ PAHI III IF FEMµE. WAS THEREA _. ff,NANCYINTHEPA$1]MDN1 ;r:Z j('{' Ages ID S41 Yes f ] No No Yey ll Hu w
<br />76p 12A DATE OF INJURY IAA, Day Yr) 26c HWROF NUURY 76p. DE SCRIBE HOW INJURY OCCURRED
<br />l..l Ar, peel �, Ilnpme,rnrrMp
<br />�l At_ M
<br />..� SurnM �_, Iro,rprrr9 16e IN.IUHY AT WORN 161 E�eEOFr ekY /gpac 'larm. sl,ael lacbrY 269 LOCATION STREETOHRFO NO CIIV pq 10WN $fall
<br />CI 14rn,rr n .•sl Dal +,n Yes ❑ N. D b M
<br />IIAif OL DEATH A /Ar Day Y,l �N ZBa DAIESIGNED /AN Dar Yrl J-1 �Bb TIME OF DEATH------ -
<br />'L - 2 -W b
<br />7Ib DAttS1�.D31U. 1,1 - -- 2- TIME OF DEATH � M � � ZpC PHONWNCEOUEAD lAkr DaY Z Be PRONOUNCFU UEAD IMY,�_- M
<br />Ip 1 n MM ws1 M my 4npw n a D,rap el J`4ma rf III— � Aua b M H pBa On Ma p..,a d a..mrna M
<br />EEEfff asagaMn, n mY epnrDn peam uccurrsE a
<br />causa,.l slaMp ♦ e TlM prna pNe erq parelanp puybTM Causelsl MaNA
<br />IND IUBAISCyCO U$E CONTRIBUTE ISwnMUn arq IpNI ►_
<br />TO THE D^EATNp a HAS ORDAN OR TISSUE DONATIONIBBE.NN CONSIDERED' pWA$CONSENT. --TED' �-�/ --
<br />❑ YES O LJ UNKNOWN [] YES IYI NO ❑ YES 1 M NO
<br />�Y NAME AND A0DRF SS RIIFIER IPHYSICIAN.CORONER$PHVSICtAN OR CWNTYATTORNEYI
<br />/I _ 13 7 Nu--4A �/ dl
<br />_ 10_ v( 2ll _�JSd�!- Ch_��__9dn_..T�te
<br />TZa Rf (.ISIRAR WTI DATE FILED BY REGISIHAR (MD DJV Yr)
<br />- laf S mart, i vlsior►r rtux/ „s(aed.( �o. N6.
<br />FOFi VITAL STATISTICS USE ONLY
<br />Reject__ _. ............... .... ...................... ......__... ... ._.......
<br />Prinlap wHp aoF InA on ra<YrlaO pagr
<br />I hereby certify this to be a true and correct copy of the orilp'nal
<br />filed with the State of Nebraska
<br />1
<br />Signe A thi of
<br />Notary Public
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<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />VITAL STATISTICS
<br />-- - --
<br />CERTIFICATE OF DEATH
<br />UEr_EI ENI -NAME -- FIRST MIDD(E LAST _ - -- SEX 2
<br />2 SEX l DATE OF MATH AM
<br />Gerald Kent Fahrenbruch Male November 2, 2000
<br />4 f;IIf AID STATE (f DIIIIH andbU54 - - -- —
<br />r name ca,rHryl 5a AGE LaM BIrI1gpY UNDER 1 YEAR UNDER I DAY 6 DATE r,1 HPNH
<br />aJ,l
<br />Holdrege, Nebraska "' �M$? DAY$ xFloDgs -MN$
<br />53 __`____ June 17, 1947
<br />I SOr, aI SECUR11Y NUMOFR -. -- - 88 PI ACE OF E TH ___
<br />MOER
<br />HOSPITAL M ❑ Nursrrrg HDr.M
<br />_ 505 -60 -3872 IrrPalr.
<br />M fAI:e ITV Name - - - - -I #elf rr 11.1A». give snrvHam mmrpevl ® EROMDNreM ❑
<br />Peavlerve
<br />St. Francis Medical Center ❑ 1— ❑ l 1n1ISPp I
<br />8l (.Ilv TOWN OII(N.At -N 1 U61N--- - - - - -- BU INSIpE C17Y UM11$ Be COUNTY Of DEATH - — " -- - '-
<br />Grand Island .a U ND El Hall
<br />9a NI SII E5 TE 9b COIlNTY _ - - -- 9c CITY ,TOWN OR I.00RIX)N - -- BD $THEFT ANp NVMRFf lAI[ fvp7rp DrrNl 9e IN5lUEf1
<br />Nebraska Hall — rand Island_ 2426 Wicklow Drive 6880
<br />UI NArF y W eBla Anw,r n TI ANCF$IRYIeg Mal an. Merr,can Germsn. etcl ----- " - - - -- - -��
<br />Ig (y-I MARRIEp [] WIUOWFD I] NAME Of SPOUSE rM xne P•vs maden ,.ar.rr
<br />elr 1 NI ISDer ryl _
<br />_ White American �NEYFII _ �DY( 1(:ED
<br />MHN Diane Schuppan
<br />1 e IISUAI (X'Cl V 1 " II C — -- -- ARD
<br />Frgdrwaa dvM Mrrr,g mr,sl lap KIND OF BUSINESS INDUSTRY T -- - - --' - -- --
<br />dar EDUCATION IS vY ngMNprane cn,r Db rll
<br />___ Salesman Retail Paper Sales L E" "a12s °^ rrlolal CMe41I
<br />16 [AIOER NAMF TID$I - -- - MIDUIE IAST - - -- I> MOWER FIRST MIDDIE -- MAIDEN SOHNAME -
<br />_ _ Al_fred Fahrenbruch Emma Sitzman
<br />IS WnS DE('.E ASFD E_ VEN III U S An C, FORCESD _ —__ RMA
<br />19a INfONI NAMF. -
<br />IYes , ur u„ I III yes prvl• war erq pales ul serncesl
<br />y
<br />_ Yes Dates Unkn_o_w_n Diane Fahrenbruch
<br />M
<br />19b INIOHANI MAl11NG ADONF SS ISIHEETORRFD NO. CITYORT(IWN SIATE - --
<br />2426 Wicklow Drive, Grand Island, NE 68801
<br />ZU FMIIAI MFR.SI(iNA NIRf AIIf,ENSE NO 21e METHOD OE D$POSN TUN 21p DA IE i1T CEME IERY OR CRf MAIURV NAME
<br />Not embalmed ❑Bpr• []HampYal Nov. 3, 2000 Central NE Cremation Svc.
<br />] ?a IIINF.NAI NOME NAME - - - -— 2Mtl CEMETERYORCRFMAIURY LOCAUON
<br />Livin stop- Sondermann F.H. EXI0 _ []D° " " °'
<br />?N. IIINk DaI 1TOME ADUfII SS IS . G- -ib- bon Nebraska
<br />I
<br />601 North Webb Road, Grand Island, Nebraska 68803 - 4050__
<br />�PIII IMMFUTAIE CAIISF IENIERONLYDNECA (15EPEn(INEFORIAIIb1ANDlc11 MarvM beNrrwr tinsel a•I
<br />_ i1/T r utcAil_. rQ �u �jr u.tJ �1pY.�Y
<br />Wt IO ON AS A CONSFOIIENCE Of
<br />IN .i��YSl GV !u
<br />11 S iY1i yun�
<br />DUF 10 OR AS A CONSFOIJFNCE " -- '- — --- - - - - -_
<br />InM,rral Mlwaen on ..r ., ,
<br />Irl
<br />PANT w4c, SGNIF CANT CONDITIONS,DMgrl DnscpMrrgMrrgblM peaM put rld raMMJ PAHI III IF FEMµE. WAS THEREA _. ff,NANCYINTHEPA$1]MDN1 ;r:Z j('{' Ages ID S41 Yes f ] No No Yey ll Hu w
<br />76p 12A DATE OF INJURY IAA, Day Yr) 26c HWROF NUURY 76p. DE SCRIBE HOW INJURY OCCURRED
<br />l..l Ar, peel �, Ilnpme,rnrrMp
<br />�l At_ M
<br />..� SurnM �_, Iro,rprrr9 16e IN.IUHY AT WORN 161 E�eEOFr ekY /gpac 'larm. sl,ael lacbrY 269 LOCATION STREETOHRFO NO CIIV pq 10WN $fall
<br />CI 14rn,rr n .•sl Dal +,n Yes ❑ N. D b M
<br />IIAif OL DEATH A /Ar Day Y,l �N ZBa DAIESIGNED /AN Dar Yrl J-1 �Bb TIME OF DEATH------ -
<br />'L - 2 -W b
<br />7Ib DAttS1�.D31U. 1,1 - -- 2- TIME OF DEATH � M � � ZpC PHONWNCEOUEAD lAkr DaY Z Be PRONOUNCFU UEAD IMY,�_- M
<br />Ip 1 n MM ws1 M my 4npw n a D,rap el J`4ma rf III— � Aua b M H pBa On Ma p..,a d a..mrna M
<br />EEEfff asagaMn, n mY epnrDn peam uccurrsE a
<br />causa,.l slaMp ♦ e TlM prna pNe erq parelanp puybTM Causelsl MaNA
<br />IND IUBAISCyCO U$E CONTRIBUTE ISwnMUn arq IpNI ►_
<br />TO THE D^EATNp a HAS ORDAN OR TISSUE DONATIONIBBE.NN CONSIDERED' pWA$CONSENT. --TED' �-�/ --
<br />❑ YES O LJ UNKNOWN [] YES IYI NO ❑ YES 1 M NO
<br />�Y NAME AND A0DRF SS RIIFIER IPHYSICIAN.CORONER$PHVSICtAN OR CWNTYATTORNEYI
<br />/I _ 13 7 Nu--4A �/ dl
<br />_ 10_ v( 2ll _�JSd�!- Ch_��__9dn_..T�te
<br />TZa Rf (.ISIRAR WTI DATE FILED BY REGISIHAR (MD DJV Yr)
<br />- laf S mart, i vlsior►r rtux/ „s(aed.( �o. N6.
<br />FOFi VITAL STATISTICS USE ONLY
<br />Reject__ _. ............... .... ...................... ......__... ... ._.......
<br />Prinlap wHp aoF InA on ra<YrlaO pagr
<br />I hereby certify this to be a true and correct copy of the orilp'nal
<br />filed with the State of Nebraska
<br />1
<br />Signe A thi of
<br />Notary Public
<br />r�� :,
<br />
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