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m n� <br />m <br />CA <br />4�i m D vc _ <br />.,r <br />U Cf� <br />WHEN THIS COPYCARRFES THE RAISED SEAL OF THE NEBRASKA HEALTH AND <br />SYSTEIK IT CERTiF1ES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REC <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC*: <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DV v„ 1S1(r t.YY 1�- <br />AS�I <br />LINCOLN, NEBRASKA HEALTH I! <br />200105736 - <br />WAN -SERVICES <br />WATS OF NEW&MMA - oeARTWO T OF HEALTH <br />N PN M OF VffAL sTATIP= g 9 14 411 <br />Col--- ATECAF0140TH M lneo <br />&�-ftmmd Now LAST <br />too <br />a DATE OF DEATH "MR ow Taal <br />e <br />e <br />em r <br />A ♦ 01w INRA►AW0/M <br />c> CP <br />E DATEar SLOTH M010L w vow <br />Icy <br />Sa r,y <br />o <br />cD <br />7'l <br />C-}, <br />MATH O vemm O 1ft0jo a0 O DOA <br />m -. <br />Z <br />M� <br />C: <br />Q <br />c� <br />ncis Skilled Nursin <br />Febraska <br />C <br />Yes <br />low <br />EA <br />TR CM. TOWN OR LOCATION K AND NUMSEN j 1 0 Z* Caw <br />O <br />y <br />_ <br />C n <br />�1 <br />, <br />Grand Island 204 S. Oak <br />Yes <br />I" wry A..�w w..R <br />,,. rs�w.► IN.r.1� D.A�.N 't <br />+a NArt OF MaAE p.w. rw .FNre+rw <br />rT; <br />lid' <br />T7 <br />ly r�J <br />C::) <br />,..F <br />�r <br />SEAAL TION AW wI0" dM *Y0y IN1r R.a <br />AF.nrE 'W`4 ow 00010/ <br />r <br />Er....rr v wwrr ►w ' aaIrEF 11-4064 <br />Housewife Qly <br />Domestic `�1 <br />Cfl <br />C` <br />cn <br />►-� <br />Cf) <br />0, +0 mwoft w •001114 - M"AA6 IST ON RV D NO_ CITY ON TOM% STATE. &-I <br />(R1�aa0R11Ia1 EIwa,RawwAM00010aMOM1 <br />andl <br />No Clinton D. Moore- Husband -204 S. Oak -Gran la <br />N <br />so< w14TtRr OR TORr • WS LOCATION OTr OR Tom STATE <br />•'`'' <br />CD <br />` <br />Al <br />- e 1 W.2n G Island, <br />Pfe <br />M <br />OWN wl Or ONE NK ANOIS Islow <br />i <br />Cil <br />TA ON AS A 010x.010001000 0100 w A00w <br />I <br />C01 Tb1-. 0w**1F111,r000066U1111010100 <br />WAS 24 <br />PART 0 IF ~ L <br />-_7 <br />2S IS" CASE REFERRED T�O'DICK <br />CT) <br />Z <br />10« caw <br />O'' 0 <br />CYO <br />rw 0 N. <br />O <br />WHEN THIS COPYCARRFES THE RAISED SEAL OF THE NEBRASKA HEALTH AND <br />SYSTEIK IT CERTiF1ES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REC <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC*: <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DV v„ 1S1(r t.YY 1�- <br />AS�I <br />LINCOLN, NEBRASKA HEALTH I! <br />200105736 - <br />WAN -SERVICES <br />WATS OF NEW&MMA - oeARTWO T OF HEALTH <br />N PN M OF VffAL sTATIP= g 9 14 411 <br />Col--- ATECAF0140TH M lneo <br />&�-ftmmd Now LAST <br />too <br />a DATE OF DEATH "MR ow Taal <br />e <br />e <br />em r <br />A ♦ 01w INRA►AW0/M <br />"" <br />E DATEar SLOTH M010L w vow <br />� S► Mm DAYS <br />Sa r,y <br />Durnstad North Dakota 35 <br />7'l <br />August 6 1917 <br />MATH O vemm O 1ft0jo a0 O DOA <br />-1915 <br />b dc"'" NW,, o ItwAF. 0 OSW mmos <br />66- d". TOWN OR LOG:ION D"t" <br />Y ANSIOE CIM1 LRNTE <br />r NN <br />M OHI1H <br />ncis Skilled Nursin <br />Febraska <br />Grand Island <br />Yes <br />Hall <br />EA <br />TR CM. TOWN OR LOCATION K AND NUMSEN j 1 0 Z* Caw <br />r am C" <br />some* rm Or to <br />Hall <br />Grand Island 204 S. Oak <br />Yes <br />I" wry A..�w w..R <br />,,. rs�w.► IN.r.1� D.A�.N 't <br />+a NArt OF MaAE p.w. rw .FNre+rw <br />.r/ <br />� (�to �,00 DNaRCED <br />Wite <br />American Married <br />Clinton D. Moore <br />SEAAL TION AW wI0" dM *Y0y IN1r R.a <br />AF.nrE 'W`4 ow 00010/ <br />Iwo OF Now" aROURETRr <br />n �' <br />Er....rr v wwrr ►w ' aaIrEF 11-4064 <br />Housewife Qly <br />Domestic `�1 <br />•}2 <br />.01000E MoDLE ,� <br />ANa1114R. MAIM "me , LAET <br />Geor a G. Lubbers <br />Johannah -- Peters <br />0, +0 mwoft w •001114 - M"AA6 IST ON RV D NO_ CITY ON TOM% STATE. &-I <br />(R1�aa0R11Ia1 EIwa,RawwAM00010aMOM1 <br />andl <br />No Clinton D. Moore- Husband -204 S. Oak -Gran la <br />so< w14TtRr OR TORr • WS LOCATION OTr OR Tom STATE <br />some Dec. 13, 1989 <br />Burial <br />Grand Island Cemetery Grand Island NE. <br />at FUNERAL 1101E - MAIE AMDAODIESS "MTIEET OR APO NO_ CRr 011 TOwRI. STAT! 21P1 <br />` <br />Al <br />- e 1 W.2n G Island, <br />Pfe <br />M <br />OWN wl Or ONE NK ANOIS Islow <br />i <br />A@WW 660000 aNa w «001 <br />IN SIUITQQNASA � <br />TA ON AS A 010x.010001000 0100 w A00w <br />I <br />C01 Tb1-. 0w**1F111,r000066U1111010100 <br />WAS 24 <br />PART 0 IF ~ L <br />AUTOF�ErY <br />2S IS" CASE REFERRED T�O'DICK <br />P <br />S A2 r AL. T"1 3 <br />YF ' <br />THE � <br />10« caw <br />O'' 0 <br />E <br />rw 0 N. <br />M DATE OF SMMIr AIS.DIM. rrl <br />2h. HOUR OF OLARW <br />Oft DESanE Now rARxRr OCCURRED <br />OR PEN)SIO WASi10ATAON w0dy► <br />09 &JURY AT w0 1a1 SIR <br />PLACE OF INAIRT . Al /ML 0a0ry• <br />200 LOCATIp1 STREET OR RFD �.., Cm' OR TOWN STATE <br />11011x► T66 er NII <br />gem wag, am 1�001Y1 <br />ETA DATE OF MATH AA. a1A W4 <br />21► DATE 900140 Aft. ar. W) <br />201. TOE OF DEATH <br />1 q 1 f Y9 <br />` <br />2Ta DATE SR011SD 0*6 D1R Wi <br />tR'a TOM OF DEATH <br />2Sc PRONOUNCED DEAD 100. Day. n/ <br />200 PRONOUNCED DEAD M1avl <br />> <br />S <br />. <br />i fl <br />tTO. TO M 660010, Ax1000/S0, x001 • M 0x66 w w Ow b M <br />266 O0 M 0000 a 010.a110aw w v .1.0119ra+\ w w aax.10 0011b eeur.00 at <br />661RN01 ohm` <br />0 <br />M 0x.10010 w 0000 w 42 0 KI a0 000NN 00000 <br />WA Too IF <br />LO T <br />Sk 00 TOSACCO USE OONINBUTE T11T 701 <br />HAS DROAN OR TISSUE DONATION SEEN OONSIDERED+ 700 <br />*A5 .ONSENT ORA 02M <br />C1 rss KNO o UNKNOWN <br />a YES X No <br />xis o No <br />ri. RAW AND AOORESE OF C6M"M (;XWAK CORMNS F11r91CAN OR COUNTY ATTO —V) 11x00 v PAM <br />S. F. Nabity M.D. 2444 Faidley, Grand Island, NE. 68803 <br />aT/ R101STRAR aa0 DATE FU0 S^ ^ w Ta" � F) <br />=. <br />YLN t J <br />—4'.' <br />i <br />LEGAL: S51�' Lot One (1), Block 148, Union Pacific Rail <br />Second Add i t i nn +-- j.,-- _ .. - <br />