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STATE OF NEBRASKA <br />. ,. : v ti ^'t ;rz . ; -,N�" :c, i'1 - .� 4 ? 7,30 t`,_— 4 �, .: - -.3rr . ,. _, <br />WHEN THIS ` COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT <br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD <br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL <br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE <br />7/12/2017 <br />LINCOLN, NEBRASKA <br />Naomi <br />STATE OF mx1N afnern U.SA_ mat eoMey) <br />.t L <br />Nebraska <br />51443 -8115 <br />aA FACLOY. Wes <br />2103 Park Drive <br />r OfTY. ToWNOOLLDCAT <br />Grand Ind <br />REINOVeCE • STATE 1 90 COLtiTY <br />It 1NCE lop, atil . MorL. Amonsa Pam. <br />tK <br />usLIAL OCCUOKnON Ow Modal rarl0xs DAN; mor f1 ) <br />el scam NIA sea Rama <br />Home Maker <br />t ‘PATTEIR. ?;NAME <br />Herman <br />bud 70:` 13 A COWSEDUENCE <br />g <br />❑ Aecs«I ❑ LY <br />1 <br />Vor. aATEOFD,EATm Ale: 0*'.. Y.l <br />• <br />2T0. DATE STONED (AN Oar y, <br />29. DID TOBACCO USE CONTRIBUTE To THE DEATH" <br />❑ YES ❑ NO UNKNOWN <br />• S A uce+SE NO. <br />Meta <br />201708421 <br />STATE OFtalaRASIlA- DEPARTMENT OF REALM AND HUI NSERVXESFINANCEANDSUPPORT <br />CERTIFICATE O DEATh 98 10 <br />gnat nlnallR9Ar an* eeamanta) <br />11. ANCESTRY leq. aelrt Awacan.OrnwU re! AD <br />rsP.e,en, <br />Amencan <br />MIDDLE <br />Walter <br />Apfel-Datier- Geddes Funeral Home <br />220 F„ IIERAL HORS - ` !STREET OA RFD. NO. CRY OA TOM. STATE DO) <br />1123 West Second Grand Island, Nebraska, 68801 -5899 <br />%REDIATE <br />PART <br />' IN Carrii A iilmnnary failur' <br />out to:bot Le= cc <br />CONDITIONS • Wiliam errelAU 0 m me NAM Our nol ARM% <br />2e2. OA OF WURY " 1. DM. W..) <br />269 INJVR1 AT WORK <br />Yes ❑No❑ <br />27, TIME OF DEATH <br />Domestic <br />25c. HOUR OF KAMRY <br />ETd TDlle 13010 mplmd+r*De. teen olxur.ar we limo. are Ens Are. Maas <br />EMIISITOMMI <br />TSgNARa Yta Tale! ► <br />9e. CRY. TOWN OA LOCATION <br />Grand Island <br />140. RMLD OF EUSWE.9S IMUSTRY <br />LAST <br />Bluhm <br />19..: INF0FARRwr. : <br />Laurence Krug <br />WAS [MEMO > V1 u.S ARMED FORCES? <br />1riEro.nu+U I W r <br />FM gm I <br />or MIME <br />No <br />%F'ORMANT Muria ADDRESS (STREET OR RF.D. NO CRY OR TOWN. STATE 21P1 <br />Park Drive, Grand Island, Nebraska 68801 <br />21a AIETNODOPDISPOSITION <br />B).M ❑ Removal <br />❑ Comam D <br />P�MJIAY % Nm+. MaQ McIOrY <br />LAST 2 SE* 3. DATE OF DRAM Matt O.Y. Year; <br />Krug Female I September 18,1998 <br />SA AGE • LAO BlndelT ORDER YEAH UNDER 1 DAY a DATE OF BOTH INN*. Day. yea" <br />(Y3') 50 005 I BAYS : 5e. NGlM16 5*45 <br />October 18,1917 <br />N <br />OF DEATH <br />HeSP(TAk. ❑ eA+leK <br />OTT LAMS <br />l2�':1 YMU® <br />❑ ER O <br />Halt <br />NagE <br />tT. MOTN9l RRST <br />Wilbetnina <br />(ENTER ONLY ONE CAUSE PER LNE FOR I% IDL AND (ell <br />PARYN.:IF FEANLE. WAS MERE A <br />PREGNANCY *THE PASTT 1 1' MONTHS/ <br />fA9.. 1 0.5 4 1 rim <br />2 : DESCRIBE HON PoAIRY OCCl1RRE6 <br />269. LOCATION <br />;CP }1t PiphCr <br />755. O w. d er�e <br />MMr.alerena <br />1912n1Aw Int TNa <br />Xs HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED <br />YES I�.. NO _.. <br />91 NA** AND ADDRESS OF CERTIFIER (FRYSIGAN. CORONER S PWYSRCIAN OR C01MTY ATTORNEY) ITlFV RAPT.! <br />(;TPTI 1 S Ln T , Grand Igi <br />a R STRAR <br />OF DEATH <br />M OATS S1D11ED 10.- Oats M I <br />9' - ZZ - ?A <br />STANLEY COOPER <br />ASSISTA STATE REGISTRAR <br />DEPARTMENT HEALTH AND <br />HUMAN SERVICES <br />("'( DIVORCED <br />g101 15 <br />OThQR ❑ * .'SHtA- <br />Relpnq <br />❑ OAM <br />101 STREETANONU1aER MeiiMDiCtdN <br />2103 Park Drive, 681101 <br />10 NOW OF SPOUSE OW, Owwiles w. <br />Laurence Krug <br />Bair a aemeep WIZ <br />64 <br />Be NODE CITY MITTS <br />4JNe❑ <br />Per <br />G DATE 21e. CESIUM OR CREMATORY MBE <br />09/23/1998 Westlawa Memorid Park ammeter <br />210. CEMETERY OR CREMATORY LOCATION OTY 00 10144 Fear <br />Grand Island, Nebraska <br />BB CABZ: 1 <br />BItMOII10RC MOMPIw • <br />Ys 1 r. r �fi►� <br />24 AUTOPSY <br />PRONOI*CED DEAD Wo Dag M) <br />STREET OR RFD. 00. ORY OR1C01 1 <br />1c�9' 8: <br />MO ;.NUIrMrI 1 <br />XU; WAS <br />jlik SE C ON ter <br />aA DOE SUr1MAE <br />Keller <br />rrlrnrewllee�errl <br />t to knnxiin <br />e�rnrreueeearlll MI.111!`° <br />a. +wECFDaraH between <br />