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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STAU., -
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE ^,COPy�
<br />'OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMEI,
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOST70Y'FQR
<br />VITAL RECORDS. •c .
<br />DATE OF ISSUANCE , t
<br />OCT
<br />1 1 STANLEY S. COOPfi,: D3$EITO�
<br />LINCOLN, NEBRASKA BUREAU OF VITAL STATI81tI6`"-
<br />STATE OF NOWASM- 11QAI11INM OF NIALTN P
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<br />SMAII OF VITAL STATISM
<br />CERTIFICATE OF DEATH .8
<br />EMT MORI um SIX DAM ce
<br />Calvin Simon Jacobsen' Made s Cember 2G, 1988
<br />-ta., ANIit'lt Ellett' ..A'1i".MMi„', - Y.IEWIr,,, uNOC TrEAII u TOE oatet�eA�Mr,.�,e.:,. }
<br />MOt. CATS NOYIi rIN/3
<br />.. 1Ge AaeGan 06 M 59 �. ,. April 19, 1929
<br />STATE Of t 'Min U-SA., CMUROT COY N S/reifjl f1AMl01lIOUil1 �iwrip"'l„)
<br />` eius, Nebraska t "H;S.A. , rtrr (,.Virginia Rieflin
<br />ErE;lElq! USUAS turATECNtGtKEid't"l! 'twiAEM K1 DOp Of1MDU3TRT C
<br />,_- 505 -30 -7118 't..rit'r' 13: rrigation Hall
<br />T3'. Well Driller
<br />CIIT. TOMTN O! LOCATION p OlATM NJi10! C1TT 1/EUT3 NO3MTAt O! OT11E! IM3TITUTION -►NI" (H"N is'ilArr, w "or M Illq, yy„ OO A
<br />Grand Island
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<br />U ows ce -3TATt 1coulm CITT. TGwM on LOCATION sTERlT AND NwEESE! M,,I" c"T M"
<br />,IL Nebraska ,1%, Hall ,S,_ Grand Island ,�. 603 W. Hagge f3i;"
<br />rMl SimeM - -- Jacobsen Lena -- I.eaburg
<br />W" CKKASIO EM w U.S. Awm mclsT INIOMIANT- NAME- leuTlOMf1rN -MAMM ACOM3S IEtEfET CN / I A TIO, CITT QABTQwM STATE ran
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<br />It. T�Virginia Jacobsen -Wife -603 W. Hagge -Grand Is an , NE.
<br />oanr�cT,ml�.!•l ept. 27, 198 cg4"'"Olc*EwATORE_MANE LOCATION CmOlTowN STATE
<br />Burial xo. 2%.Westlawn Memorial Park mm. Grand Island, Nebraska
<br />ARM ajlcfmu No. 1Y3 A NNEEGt -NAME AND ESS rSTEEET a A.r.o. NO. Cm a TowT4 STATR iMh
<br />( �pfel- Butler- Geddes 1123 W. 2nd, Grand Island, NE. 68801
<br />mm 01 Iftyk t 08"'.) C DATE 3WHID (A4. Day. Vt.) "MR OF OIATHI
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<br />- VAT9 SIGNED
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<br />LLL David Howe M.D. Hastings Medical Park, 2115 N. Kansas, Hastings, NE. 68901
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