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89100383
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Last modified
10/19/2011 4:29:19 PM
Creation date
10/20/2005 9:12:53 PM
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DEEDS
Inst Number
89100383
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r- <br />89- 100383 <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE <br />r DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE--,A JOVE COPY <br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE JltpAitniNT & HEALTH <br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL. ORPOSITORT-1XIR <br />VITAL RECORDS. �. •" <br />DATE OF ISSUANCE�� <br />Nov 1 im STANLEY S CQO CTOR <br />LINCOLN, NEBRASKA BUREAU OF ilTAi tgTiATISTICS <br />STATE OF NEBRASKA — DEPAWMElr (W BMTH <br />Bureau of Vita! St•tktke r A� <br />CERTIFICATE OF DEATH (-,. _ 4!. �, 1 <br />A ,..13 Q B O <br />D[C[A$iD -fTAM! RH1 tswNf qN <br />IIA11 OF DEATH 1 NgmKw. *AT, VISA n <br />1. ,EC of 4 T RkLe. <br />a now. 30, 7 T <br />RACE WN01. wow. AraItAN M WN. <br />ACE -w1 <br />WN@ t / 11101$ <br />MT OAR CM ER "I- —. I.T. <br />COUNTY OF DE413 <br />llpf, MTY <br />wO1M! <br />fit IfVECMTt <br />NnIM ►t ITWat <br />lse <br />0M. TMfl <br />8 7 <br />G floAk <br />f <br />37 <br />la <br />Tt_ <br />A R <br />_ <br />CRT. TOWN. OR ta"T10N OP mo <br />11bSIT1At OR OT11M V4STITIRION -KNEE• IP TAO, rot IIMn. aN$ u$n, AND turn 1 <br />T K� No <br />1111. <br />w tic <br />4W4 <br />t•. St 74an td 1164 <br />STATE Not w Y.S... I/Aw <br />Cmn".. of *ffw- Y <br />M"011D. NEVER "wo. <br />SURYNR'Q MUM tIr woe. am "Aw11N Num t <br />ealafIN• t <br />WIDOWE—D, f1Kat l <br />R <br />T. � <br />—oN_O_RC-E—O JI <br />M alfL�l�i{.�AL <br />�� �� I���` <br />11 f7a�Q ITIf.SJA.f:/4 ^, <br />SOCUIt SECURITY NIU1E11 <br />UWALe K Or ,TOM 00"t fYNNO 64051 Of <br />13M Of RUSMW O! itR1N M <br />(� T! NnNY rue <br />It 50 5-3ft- 17-1 '13i <br />✓ <br />I• Sha TQ- t*AMT <br />IIESID&RX- TATS COUNTY CRY. TOWN. OR LOCATION INNN tow toot,. STMT <br />ISM." HIS Of NO .. <br />�1;v� p <br />IN m. 02 Sme <br />nfN -Into Wt A601MR� -AMDEN N.WE lots, 0O.IO ust <br />EiATHN-NAME <br />- C.ratra�rtgk.� n• Ranee U. <br />EASiO EYER W U.& ARA1E0 t'ORSE$T 9*01014ANT — NAMC- Re1AT1pNSNN- MA%04G ADORES$ I►lffw O$ e.t.a. Ato.. Cis, OA V-W. %,AN. two <br />da$n64) M ,I.Y.•••••r•• <br />'- ne 68824 <br />gw4 - Q2 S CatAg -t <br />DEATH WAS CA M IM JINTE1 OfNY ONE CAUSE EEf IRIS"(a). Iy. MO dc)i <br />M/Tn1w owat wtr $tAtw <br />wMaw-M CAM <br />N) <br />1 COP;1HF ws, n am <br />WHICH oaw 'S tH <br />w � <br />rAtyMa14 CAYB w. _ OW w. p AS w CONNOIotwc11 Or: <br />tt.T /Nw 111 YNafb <br />- <br />TtW. CAYN lA,t <br />I <br />01 <br />PART 0. C7---zg?ieij afiolE'KIYT 10 WRATH T NOT RIIATI�O <br />PA111 I& r MIEAL& WAS THRM A <br />AUTOPSY <br />IF iii will t /N$INaf COIF <br />TO CAUSE 11N FAIT ' <br />M10#0111CY M TNI PAST ! 001f1NSt <br />I Rf O$ trot <br />Mv I- N1tf641NYr0 cAYN <br />M Matw <br />MO NOD <br />I1$ <br />111. <br />- A9O1)6 R. SILK=. . <br />CNattt64. D.t: tlAf 1 <br />NOW INIURY OCCURRED towel$ "Allow OT INlan IN ran 1 ON rAn 11. $1- is I <br />' OR umoETERNMdo II1KIRI • <br />.. - <br />NL <br />Tot. M <br />SRI. <br />IMAM AT <br />RAMIGIF @00VAT war. 1Ar.. IrTwN. 1ACTan, <br />LOCATION / ftfl$1 on ,.6401. NO.. Coll ON 10641.. WAIN t <br />I SVKlw w, W Not <br />OTrld'IIW.PC. INKIwr <br />CERMKATION— -Ow,a MV TAY -OWN $AT VTAa <br />AtO u61 "If Has /q! N.T, ON I Brow W" TIP, Nlf <br />GRATIN OCCUSSIO Al aw V%AW. O. 1111 <br />rNTSKIANI <br />1 A/IN N,fa tw! TO <br />-at11N YAt RA. saw AM NAM. <br />In IIN <br />rNoy,t �r 9M. AM, t0 IMO MST <br />ON ngWUMN. VA <br />ilA N1bf1. NOr L fr TI►. 73 <br />1 <br />/ — o _ 73 <br />:If. ►� to aw cAyN14t <br />ClRTi1G►llOff— MEOKAt EAAIM�IT CIR R: O- 1110 $ANI Of 1111 way$ O. NAM <br />1wf Mc11ofNt 6401, rlOwOYwcfp NAY <br />,Iy164$IATIYN Ot 1111 ,Olt wMYIO$ 1111 wwwo "ON. IN NT OPWIOw. <br />AIOtaN MT TfA$ "Owe <br />NAM Ow ON MR AIM ,If 10 he CAYNIS/ StA116. <br />M <br />Tae M <br />=/ra <br />fps., <br />t IsKiff I <br />OA .. r .0w*. Mt, T11.r. fUtWIPA6 MOMS -NAME AND ADDRESS . /141111 ON 11.1 Y. <br />„. 4 1-97-3 <br />is A Tun eJta.L f{aaee9� <br />`?E R- SIONATUt a ISCE"M NO. _ as / !�'' REGISTRAR- SIC.NATU$ <br />- <br />Ffl t - 7 -3 <br />AIN TN <br />G <br />>M Cm M ITAtf <br />rG.tJh,Q, nP. ka4&a <br />c" e to.-- t,••Reti bz 68883 . <br />/ 1111 11 ,Opt lfewfAAA <br />7 <br />—I <br />1y <br />U <br />co <br />U) <br />r <br />r <br />r. <br />R, <br />
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