|
The South Half of the Southeast Quarter (S1 /2SE1 /4) of Section
<br />Twenty (20), Township Eleven (11) North, Range Eleven (11), West
<br />of the 6th P.M., Hall County, Nebraska, EXCEPTING a tract of land
<br />more particularly described as Lot One (1) Roxboro Subdivision
<br />filed as Document No. 90- 101644.
<br />6
<br />The Northeast Quarter of the Southeast Quarter (NE1 /4SE1 /4) of Q>
<br />Section Five (5), in Township Eleven (11) North, Range Eleven (11), ( cD
<br />West of the Sixth P.M., Hall County, Nebraska.
<br />OF - -
<br />COMMONWEALTH OF VIRGINIA, � \
<br />DEPARTMENT OF HEALTH - DIVISION OF VITAL RECORDS
<br />COMMONWEALTH OF /IRC11V1A- �- CCRTIFICATE OF DEATH
<br />\�rU� \"
<br />09PARTMENT OF HEALTH— BUREAU OF VITAL RECORDS AND HEALTH STATISTICS --RICK Ii, O
<br />"REGiSt RATl O'N"
<br />rn
<br />-
<br />]STATE FILE
<br />n n
<br />AREA NVMBER 101
<br />p
<br />c� cry
<br />NUMBER
<br />�'ry
<br />1 E NAwE Rr>tl Im dtllal (Attu
<br />EO
<br />2. SEX mW
<br />(NMN) -.
<br />_
<br />>1 Q
<br />.-t
<br />2
<br />D
<br />5. AGE IF V 'DER 1 YEAR IW UN`D' ;R'} DAV
<br />6. DATE OF Imo I Id") I~
<br />T A PE(iT�ENT
<br />a
<br />monkba T dsyx— boun mmueet
<br />I
<br />N
<br />I
<br />8 NAME OF HOSPITAL O STITUTION OF DEAT if one so hates w �.rr no.rry +•r/
<br />I 1 oon nm
<br />m
<br />Z
<br />PM
<br />O
<br />C DD
<br />t t°ITY OR J DEATH y auto 6ty pr wwn fo"PIO
<br />M
<br />T TREET ADDRESS OR AT. NO. LACE OF DEAT
<br />f
<br />,
<br />O', 7 OF OECEASED'S RESIDENCE (rt 14 --. city, leave. - blank)
<br />C=)
<br />Rockingham
<br />7C
<br />e CITY OR TOWN OF RESIDENCE 'M <Ity or to..n Iimitai
<br />15, STREET ADDRESS OR RT:040. OF RESIDENCE l ZIP CODE
<br />r go ur Cq ®;
<br />1531' North Colle a Avenue I ?280
<br />a NA o00A7HER OF OiECEASEO -;!
<br />17 MAIDEN NAME OF MOFHEH"OF PEKE ASED
<br />y
<br />ac `
<br />q# rta". Rot, I
<br />'1B
<br />✓,�IT 126N AZT U�HAT 4pl1'iNTRW
<br />1S, B4RA'1iPkACE 4518Lq prpbLni!Yl
<br />A(}R liD.1'l
<br />DIVCIrdG`ED❑ $V;
<br />iJJ ''
<br />{T ARFUE01,0 JM 44�a` NA.CoPawO�l1S�:
<br />'.,
<br />..
<br />_
<br />E-M
<br />.:.
<br />, Q.
<br />i t pNOrced NaYF Wtlnlv'A ,"
<br />G Sr Gaib r- S6hu
<br />22 SOCIAL SECURITY NUMBER
<br />23'tlaUAL OR LAST 6CCUPATIf�1R
<br />2e KIND OF'S � !,SS ORINDTTRY 25
<br />�e'
<br />Z
<br />X
<br />0
<br />y
<br />n ".G#p
<br />Ster
<br />;� ��
<br />er
<br />�A
<br />\�
<br />2e ,y%�dISE\`�"l q ATH tE1o,We oA4y tour. per lln<tpt tAl IQIye� tcl 1 'V '� " I.I ``
<br />` *AT I, itEATM t�7,NU5E17 "#` ' l,'; li
<br />NTIRVAL 0ETWBEN
<br />o'N6ET AND
<br />WA5 I i t �, l
<br />MIMED A'E`CA USE IA)
<br />�E RLTH
<br />11 V
<br />_,,,,,
<br />i
<br />DVE;TO
<br />11� —
<br />2Vhr
<br />,B
<br />I v 9Werw
<br />0.ILAm p'et ` !B (A fA) taring tMt
<br />Vtldgky nq caV �I. t ,(1_ "RRRRR ,
<br />_
<br />�.
<br />DUE TD IG3 ff�f ` _
<br />1 S
<br />PART II. OTHER SIGNIFICANT COND TJONS CONTR IBUTtN.G TOO T. 991 NOT ELA ED TO TSIE TERMFNAk -�.
<br />]fia AUTOPSY1 y nd
<br />DISEASE CONDITION GIVEN IN FA RT )CAI
<br />AUTHORIZED SY.
<br />260. IF FEMALE, WAS THERE A PREGNANCY
<br />26c. IF E XTERNAL CAUSE, IT WAS
<br />26tl. DESCftIRE HOW INJURY RELATING TO DEATH OCCURRED
<br />IN PAST 3MONTHS'
<br />. una
<br />y «p q❑ ---E:1
<br />►—+
<br />M
<br />261E INJURY OCCURRED)
<br />PLACE OF INlURV (home tam ]6N. (city or town) (FFNIPIWl L.Aiee
<br />Ay
<br />tacior1 --t, oItk. bldg etc,) I
<br />26) to the b"t of my knowledge, Occurred at '� ' 'ra (do.) (p.m.) on the date and place end from the ceoloisl ;toted.
<br />-- — TDATE SIGNED: — -w
<br />ACTUAL ��j / � —��
<br />CT ATURE ! I
<br />- f//
<br />NAME OF ATTENDING PHV�AN rpw ,nrl / IAODRESS OF ATTENDING PHYSICIAN ���J�
<br />GGG
<br />L- j,NLZ41142d J. 44,c 'r W) I qM I' A-
<br />•
<br />a
<br />The South Half of the Southeast Quarter (S1 /2SE1 /4) of Section
<br />Twenty (20), Township Eleven (11) North, Range Eleven (11), West
<br />of the 6th P.M., Hall County, Nebraska, EXCEPTING a tract of land
<br />more particularly described as Lot One (1) Roxboro Subdivision
<br />filed as Document No. 90- 101644.
<br />6
<br />The Northeast Quarter of the Southeast Quarter (NE1 /4SE1 /4) of Q>
<br />Section Five (5), in Township Eleven (11) North, Range Eleven (11), ( cD
<br />West of the Sixth P.M., Hall County, Nebraska.
<br />OF - -
<br />COMMONWEALTH OF VIRGINIA, � \
<br />DEPARTMENT OF HEALTH - DIVISION OF VITAL RECORDS
<br />COMMONWEALTH OF /IRC11V1A- �- CCRTIFICATE OF DEATH
<br />\�rU� \"
<br />09PARTMENT OF HEALTH— BUREAU OF VITAL RECORDS AND HEALTH STATISTICS --RICK Ii, O
<br />1 i
<br />r �
<br />rte
<br />°o`P r"eap. e i. , Is S s a rue a QIeC uc i6n Or abstract o the official rotor a WI lrgirna Department
<br />MlltREtyp 4 Of
<br />Health, Richmond, Virginia
<br />;_ EKG LV /Y " 4i
<br />a a DATE ISSUED May 8, 2001 l
<br />a = = Deborah Little Bowser, State Registrar
<br />paper �^ 2 Code of Virginia
<br />% Don VS 1�
<br />nTis as amended. t unless on security l er wdh seal of Vital Statistics impressed. 82 1 27 I-111'll II III IIIIIIIIIII III 1,,�= �LL�uII
<br />4 t --
<br />p y tics clearly im ress d Section
<br />011 itiA' A3110 ;Wi 9N I, 1A 81 :411Wi 1`08:a:I:1 1;?aii::1YA it%:N: -J9
<br />"REGiSt RATl O'N"
<br />CERTIFICATE
<br />-
<br />]STATE FILE
<br />AREA NVMBER 101
<br />NUMBER ^ ^�
<br />Ly
<br />NUMBER
<br />1 E NAwE Rr>tl Im dtllal (Attu
<br />EO
<br />2. SEX mW
<br />(NMN) -.
<br />>1 Q
<br />tJvATE OF;; d7 idgy) tg ,
<br />OEA TH
<br />5. AGE IF V 'DER 1 YEAR IW UN`D' ;R'} DAV
<br />6. DATE OF Imo I Id") I~
<br />T A PE(iT�ENT
<br />a
<br />monkba T dsyx— boun mmueet
<br />RY R'Fw
<br />ARMED ORCESi tIe
<br />I
<br />8 NAME OF HOSPITAL O STITUTION OF DEAT if one so hates w �.rr no.rry +•r/
<br />I 1 oon nm
<br />9. COUNTY F f�E ATH Irt InlNpende t CitV. lone blank)
<br />t
<br />y -tt �
<br />'
<br />t t°ITY OR J DEATH y auto 6ty pr wwn fo"PIO
<br />M
<br />T TREET ADDRESS OR AT. NO. LACE OF DEAT
<br />f
<br />l "ATE foR FOREIGN. COUNTRY) OF DECEASED'S RESIDENCE
<br />O', 7 OF OECEASED'S RESIDENCE (rt 14 --. city, leave. - blank)
<br />ViriginiA
<br />Rockingham
<br />e CITY OR TOWN OF RESIDENCE 'M <Ity or to..n Iimitai
<br />15, STREET ADDRESS OR RT:040. OF RESIDENCE l ZIP CODE
<br />r go ur Cq ®;
<br />1531' North Colle a Avenue I ?280
<br />a NA o00A7HER OF OiECEASEO -;!
<br />17 MAIDEN NAME OF MOFHEH"OF PEKE ASED
<br />SeI Ga tho
<br />ac `
<br />q# rta". Rot, I
<br />'1B
<br />✓,�IT 126N AZT U�HAT 4pl1'iNTRW
<br />1S, B4RA'1iPkACE 4518Lq prpbLni!Yl
<br />A(}R liD.1'l
<br />DIVCIrdG`ED❑ $V;
<br />iJJ ''
<br />{T ARFUE01,0 JM 44�a` NA.CoPawO�l1S�:
<br />'.,
<br />..
<br />_
<br />E-M
<br />.:.
<br />, Q.
<br />i t pNOrced NaYF Wtlnlv'A ,"
<br />G Sr Gaib r- S6hu
<br />22 SOCIAL SECURITY NUMBER
<br />23'tlaUAL OR LAST 6CCUPATIf�1R
<br />2e KIND OF'S � !,SS ORINDTTRY 25
<br />ISEORMANT Oil$OURCE'O,f IR,,ORMATION
<br />I
<br />'
<br />\
<br />h. �'
<br />n ".G#p
<br />Ster
<br />;� ��
<br />er
<br />�A
<br />\�
<br />2e ,y%�dISE\`�"l q ATH tE1o,We oA4y tour. per lln<tpt tAl IQIye� tcl 1 'V '� " I.I ``
<br />` *AT I, itEATM t�7,NU5E17 "#` ' l,'; li
<br />NTIRVAL 0ETWBEN
<br />o'N6ET AND
<br />WA5 I i t �, l
<br />MIMED A'E`CA USE IA)
<br />�E RLTH
<br />11 V
<br />_,,,,,
<br />i
<br />DVE;TO
<br />11� —
<br />2Vhr
<br />,B
<br />I v 9Werw
<br />0.ILAm p'et ` !B (A fA) taring tMt
<br />Vtldgky nq caV �I. t ,(1_ "RRRRR ,
<br />_
<br />�.
<br />DUE TD IG3 ff�f ` _
<br />1 S
<br />PART II. OTHER SIGNIFICANT COND TJONS CONTR IBUTtN.G TOO T. 991 NOT ELA ED TO TSIE TERMFNAk -�.
<br />]fia AUTOPSY1 y nd
<br />DISEASE CONDITION GIVEN IN FA RT )CAI
<br />AUTHORIZED SY.
<br />260. IF FEMALE, WAS THERE A PREGNANCY
<br />26c. IF E XTERNAL CAUSE, IT WAS
<br />26tl. DESCftIRE HOW INJURY RELATING TO DEATH OCCURRED
<br />IN PAST 3MONTHS'
<br />. una
<br />y «p q❑ ---E:1
<br />r r„Zep
<br />26e. TIME OF IN,II�RY Imo.) Id.,) Near)
<br />261E INJURY OCCURRED)
<br />PLACE OF INlURV (home tam ]6N. (city or town) (FFNIPIWl L.Aiee
<br />Ay
<br />tacior1 --t, oItk. bldg etc,) I
<br />26) to the b"t of my knowledge, Occurred at '� ' 'ra (do.) (p.m.) on the date and place end from the ceoloisl ;toted.
<br />-- — TDATE SIGNED: — -w
<br />ACTUAL ��j / � —��
<br />CT ATURE ! I
<br />- f//
<br />NAME OF ATTENDING PHV�AN rpw ,nrl / IAODRESS OF ATTENDING PHYSICIAN ���J�
<br />GGG
<br />L- j,NLZ41142d J. 44,c 'r W) I qM I' A-
<br />- /+* •�� ,AL/ �v
<br />2Y' eURIAL, REMOVAL CREMATION
<br />28. PLACE (-6 oiIFooeYNvV OY'a'Nmmeror ). (Cry wconntyl taeatal
<br />OF BURIAL,
<br />❑... �
<br />REMOVAL, ETC, ion MW nno '� to Da )qon Virginia
<br />♦ Yn /�yPy Cemetery,
<br />:. ( htttluAeY•I v n Ina Y filing a<ertdt<e NAME OW PO"ERALKyger ro aug Funeral o
<br />/ Home aND J b b
<br />/ ADDR €50
<br />Harrisonburg, Virginia 22801 .
<br />b. , ' atVn of rapbperl DATE RECORD
<br />FILED: 4/21/82
<br />✓
<br />1 i
<br />r �
<br />rte
<br />°o`P r"eap. e i. , Is S s a rue a QIeC uc i6n Or abstract o the official rotor a WI lrgirna Department
<br />MlltREtyp 4 Of
<br />Health, Richmond, Virginia
<br />;_ EKG LV /Y " 4i
<br />a a DATE ISSUED May 8, 2001 l
<br />a = = Deborah Little Bowser, State Registrar
<br />paper �^ 2 Code of Virginia
<br />% Don VS 1�
<br />nTis as amended. t unless on security l er wdh seal of Vital Statistics impressed. 82 1 27 I-111'll II III IIIIIIIIIII III 1,,�= �LL�uII
<br />4 t --
<br />p y tics clearly im ress d Section
<br />011 itiA' A3110 ;Wi 9N I, 1A 81 :411Wi 1`08:a:I:1 1;?aii::1YA it%:N: -J9
<br />
|