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STATE OF NEBRASKA <br />sA <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 />3/23/2018 <br />LINCOLN, NEBRASKA <br />t 019 AND STATE OF eRTH a,ale USA Aar oalweyi I S! ACNE - LAN RTasy 14062 YEAR UNDER t DAY I. DATE OF BIRTH Moen Ow l J <br />IYn So. % I DAYS H <br />Sc. OURS e1A5 <br />St. Fain, Nebraska 78 .S , January l8, 1922 <br />SOCML SEWRtm *AMER A RLAOE -OF DEATH <br />S(., -20 -2747 > r� 0 Mo..., OTHER <br />64 FAGUTY - Na9Ia ATreM.eeeOalaA paw l�aa iarrO Ml?MI ER Weiler* 0 Femme. <br />Park Place Health Care Center <br />0 DOA One ,sue <ti <br />Se CITY towN DRNOCATION OF DEATH WEAN CITY 14279- Se COUNTY OF DEATH <br />Grand Island <br />yes w, 0 Hall <br />9a RESIDENCE -STATE 90 COUNTY 9C CITY. TOWN OR LOCATION 94 STREET AND NULiBER brckdr�Z42 Cptlp; � 9, INSIDE CITYLYfS <br />Nebraska Hall G and Isl and 610 N. Darr 68803 1 Y« Nd rl <br />00- Fmcz-NA- YANM::LIl.:A.. Me' <br />1677 I°'°"' White <br />Ma USUAL OCCUPATION One r a.GYAWno & gmost <br />Hous <br />11. ANCESTRY tog.. aasac Meur:Tn Sineetr;':162 <br />` <br />Domestic <br />?Q FATHER - NAME <br />10, W S:PC -01 "/CSEO <br />ngno o. uyc} I <br />199. INFORMANT <br />/I L <br />221. FUNERAL • NAME <br />Apfel- Butler- Geddes <br />23. <br />PART <br />kI <br />ODE <br />A COHSE <br />1.. <br />1009 W. 4th tit., <br />November 23,2000 <br />0 To9r;. . foY <br />� c+ 4aal 70,5aNd . <br />*WT <br />29 DID TOBACCO. USE CONTRIBUTE TO T <br />MAILING ADDRESS <br />rum OF MOM AS U6 OMMUU ENTOF HBAli.'IH AND HUMAN SE mms FummicE AND SLlmaT <br />c am c DEATH 00 13118 <br />IN U.S. ARMED FORCES? <br />X mit eve raralddans wseeraael <br />URE & LICENSE 210. <br />eat IteN ti i2 <br />CONSE0UENCEOF <br />RRS7 MIDDLE i/IST :2 SEX 1 13 DATE OF DEATH Atli*, O a4 ar Ya <br />Josephine Irene Beberniss Female November 23, 2000 <br />FIRST MIDDLE <br />William <br />S CA <br />299 DATE OF INJURY /Rio. Oa <br />27b. DATE SKTiED em Day Yr I 1 27c TIME OF DEATH <br />1 <br />November `26,20•0 12: <br />urra4 at the <br />201802011 <br />Yr/ <br />149 KU20 OF BUSINESS INDUSTRY <br />Lo5T <br />Bennett <br />17 MOTHER <br />1 9A MNFORMANT ;NAME <br />LeRoy Beberniss <br />(STREET OR 6 F D 240 CITY OR TOWN. STATE. WI <br />. FUNERAL HOME ADDRESS (STREET OR RFD. NO. CITY CIR TOWN. STATE 21P1 <br />Grand Island, NE. 68801 <br />?dz., 21a ME'TNDDOFDLSPOSITON 2tb. DATE <br />Br,raI ❑ T.va. Nov. 27, 2000 <br />❑ ^< [� Dom. <br />1123 West Second, Grand Island, NE. 68801 <br />(ENTER ONLY ONE CAUSE PER LINE FOR of Ib1" AND 1111 <br />p Acodint p Uudestrened <br />I p Suede p Penang 26. INJURY AT WORK 1 261 dM Euxd^9NJURY f 909*, Ivm 9r+er W16Y <br />L.,.I RIOrluda 1 ilTaea9a'dn. Tae u No D It <br />• <br />:�7a DATEO{'0EATH 244,. Oar 9,) <br />M <br />UNKNOWN YES <br />AND AMIESS OF CERTIFIER IPHYSICWI. CORONERS PHYSICIAN OR COUNTY ATTORNEY, Typcur A.+n <br />17 3 MARRIED r'e WIA0WED 1 13 T NA , M , EE OFF SPOUSE a r r , 4 g i mown ewe* <br />NE D i{�7 DIVORCED LeRoy Bebernl.AT.aa <br />FIRST <br />Lottie <br />214 CEMETERY OR CREMATORY LOCATION <br />269 ; LOCATION <br />STANLEY COOPER <br />ASSIST 7 STATE REGISTRAR <br />DEPARTMENT HEALTH AND <br />HUMAN SERVICES <br />PRONOUNCED DEAD <br />I 15 EDUCATION ISach a69 Wool wade cae4Yef4* <br />1 EMrreunf r Semi 0-12 C bees s u 5-, <br />14JDLE <br />21 c. CEMETERY CR CREMATORY <br />MAIDEN SUAI M E <br />Holsinger <br />Grand Island Cemetery <br />OTT OR TOWN STATE <br />Grand Island, NE. <br />Condoms cure tine lee Ceadr but not reeled PART III IF FEMALE: WAS THERE A 1 24 AUTOPSY t <br />• PREGNANCY IN THE PAST 3 MONTHS' <br />(Ayes 1057; Tae n No n I Yes r1 No 5 I <br />26c HOUR OF INJURY ' 26d DESCRIBE 440W WUURY OCCURRED <br />STREET OR R F O 640 <br />RR, TIME OF DEATH <br />A R Der '2 2a4 PRDND_LNCE0 DEAD Op., <br />tae `:a M uoue of b5 84 tC O .wafeg. w.. 9 ay OPHPr *49* acaPAPP JI:::.: <br />� •9 Amp: MIA 9* d►.e *40 9be D eta Gamer SIAM <br />Saatre an9 <br />30 HAS OoDAN OR TISSUE DONATION BEEN cNSOEAED 300 WAS CONSENT COMMT D> <br />Merry *499. WOO an0 6464 <br />-Zak. <br />Moral bearMn 0 One 4eaP■ <br />WAS CASE RED TQ:LEDICAL <br />EXAMINER OR — I' G'f BONES <br />7)TY OR TOWN. STATE <br />Dyes <br />Cyan D. Crouch D.O. )) 800 N. Alpha Ave., Grand Island, NE. 68803 <br />32a REGISTRAR . 32e 07-TE F9 E0 69 6666THA Air Om 691 . <br />DEC 12000 <br />469* <br />0 <br />co <br />W <br />