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ate Ak <br />STATE OF NEBRASKA <br />taltia4 1114 eAdf <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 />1/31/2018 <br />LINCOLN, NEBRASKA <br />l CRY ANO STATE OF OWN ono it USA. IM.Ai Try, <br />SOCIAL EECURWr/AMBER <br />S08 -22 -5628 <br />e6 FACILITY. Nam <br />EL flESfOE-STATE <br />Nebraska <br />fD RACE - asovas, auk. Am,iT/n tom. <br />(s41.ah1 White <br />V S U A L D C C U F A T 1 0 N ene a r e a / rat d o n e <br />orMay* WA OW INOW) <br />Meat Inspector <br />FIRST <br />Joseph <br />22A, FUNERANDME ADDRESS (STREET OR RFD. NO CRY OR TCUIN. STATE, 21P1 <br />21 AMIEDIATECAuSE <br />POPT <br />1 50 <br />DUE TO. CA AS A <br />P COINo*maNWgJo sr AR <br />cB 1 ai � e r, <br />a1.. aeb TE PWRY A1Q A iec <br />❑ NpN <br />1903 W. 14th <br />. TOTIHOItOCAi1ON OP DEATH <br />NEGORIVIR <br />446 S. Main, <br />Edger, Nebraska <br />Grand Island <br />AE <br />►+n+gran <br />Floyd <br />21A DATE. CFDEAIN <br />315 To ' Rey <br />ae>.R• fist <br />1EE�ItrE AM TON • <br />cowman <br />TEa ❑ NO <br />a1 NON AND ADORES. OF cen Est ;roman** <br />FAST <br />Sitki;Copur, MD, 2116 . <br />NOME <br />mane <br />If far UMIaei It '4m / <br />11. ANCESTRY log. MOM Madan, Drmn: <br />1SD Czech <br />201801042 <br />Zikmund <br />1903 W. 14th, Grand Island, Nebraska 68803 <br />... 21 Df D6PD$h e <br />Soma �n+wiY <br />PO Box 431, Nelson, Nebraska 68901 -0431 <br />Zee. INJURY At WON( let IM Aar Iwo mewl Mary <br />OM ❑ NA ANTROFF ge <br />'7/21/7'9 <br />SfAIRCe d3BRASMIIBtAltiliENT OF HEALTH AN0 Hd1AlAN SERVICES 1 AND SIAIFORT STATISTICS <br />CERTIFICATE 99 08745 <br />LAST 2 SEX a GATE of DEATH Alb 1E p,, NITq <br />July 28, 1999 <br />5A AGE - UMMarr5v <br />nll <br />72 <br />ea FAERIECITY:UMR3 <br />11 KP7DDFsuswaSE <br />Goverment USDA <br />PN <br />M <br />S PLCTM O A OATS ATTORNEY • T mow P.m <br />Z ikmund Male <br />wean' YEAR UNDER I oar t TE OF SETS emim O.,. ANN <br />SO. MOS. DAYS. 50 NOUNS ' MINS <br />September 4, 1926 <br />r PLACE OFF DEATH <br />I[C6PR4. ❑ rio.WP WREN ❑ timing Nba. <br />❑ ER OXMAN Q RMIARN• <br />❑ am (eoahi <br />❑ <br />Y: COUNTY OF DEATH <br />Hall <br />Ye. E3 +b <br />( i0. COUNTY Tc C DR - ?ION 1. STREET AND TAMER onag vsoOMN <br />Hall Grand Island I 1903 W. 14th 68803 <br />12 0 MARRED ❑ NOOSED <br />❑ NEV6l ('1 DIVORCED <br />YennFa L <br />over <br />Georgia <br />;1a WAS DECEASED_ 'EVER IN U.S. ARMED FORCES? RSA INFORMANT - PRIME <br />Ms fO. o Ars) At mu Nye wvne dem al seMA O <br />Yes I WWII 12. 27-44- 11 -19 -46 Mercedes Zikmund, Wife <br />150 INFORMANT MA4NE ADDRESS (STREET OR RFD NO CITY on TOWN. STATE a a) <br />Klawitter -Price Funeral Home <br />215 DATE <br />July 31, 1999 <br />2.A CEMETERY CO CIE IATORY <br />Nelson, <br />L ONTECI ONECAWE aw AP. AFp <br />obtslotc A Co4 <br />PART • t FEMALE WAS RAPE A 24 AMIOPSSr <br />MEGoam YMTIE PAW? 3 fAONTIp <br />2tI DEICFIEerosauum, <br />2Ie L."7CATTp1 mum? ca R,FD TD <br />71 Ay/ Qq <br />S aM: A *ram Wearralmwf <br />0 . aiewrwRUPare <br />y a7 o ATAI► <br />ae. NAS *um ORT emu* 00NAnpls / al/Elt� <br />❑ YES L7 "o <br />Rae Wm AAA awe w <br />as DATE:MIMEO Ma OW <br />dley A e. Grand ISIInd, Vebraska 68803 <br />i ism auE`a►e. <br />STANLEY COOPER <br />ASSIST STATE REGISTRAR <br />DEPARTMENT HEALTH AND <br />HUMAN SERVICES <br />Te IC+!r <br />Yee 3 No ❑ <br />13. NAME OF SPOUSE r.ek pwAUNM1 erm <br />Mercedes Henriksen .. <br />{ 15. EDUGTIDN masa, ardy pale caT141 A <br />5e3MY m Emissary t0-121 COINON 114 Or 5.4 <br />SIC CBN:TERV OR CREMATORY . MANE <br />TON CRY OR TOWN <br />2010 la r/ <br />Nelson Cemetery <br />raska <br />s <br />7 9. <br />1,...- - -rte" ?t <br />a MISCR/EREPEMEOTOeESRX <br />60RSI43111CQ4eYa <br />Er le 17_1 IFF,111 <br />5 ' 0 1) <br />