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-40 ZWY <br />- v THIS COF .cAaatE� TBE BAISEQ sE!!I. OF Ta NESRAM Su 105014- <br />... - _ . - • - - -- '-TAX+!►a!•��liriri►-i�ws±�+f'! -mss+ -_ �--v�i��raki�wrna - rs. A- May" -- - - — -- <br />OF AN ORIGINAL RECORD, ON .FIGS WITH THE STATE - DEFAR'i'!�T• <br />BUREAU OF VITAL STATISTICS, MICH IS -THE LEGAL UR <br />vim WORDS. <br />DATE OF ISSUASCE .JJ <br />AM STANLEY' S. CCN�I�Pit..DIAh.CTOR <br />LINCOLN, NEBRASKA BUREAU OF 9ITA1,= TkTISTIGS - <br />STATE OF NEMASM — WARTII W OF HEALTH <br />`. SUrA i OF i ITAL STATi IM , <br />• 1 Cff (MATE OF OEATWa <br />L <br />l <br />` t DECEDENT -NAME FIRST MIDDLE LAST <br />2 SEX <br />7 DATE OF DEATH (AAve Day -ml <br />Devere Abel Swanson <br />Male <br />Jul 27, 1990 <br />. CRY ANO STATE OF BIRTH fonts USA IVNira"VYt <br />Sa AGE -LAM Siffax r <br />+ <br />B DATE OF BIRTH IAAWW Oft Yid! <br />Sb MOS a.AY$ <br />SL NOUAS MOI,S <br />(YtxI <br />- <br />Stromsburg, Nebraska <br />76 <br />May 19, 1919. <br />T SOCIAL SECURITY NUYBEPI Ba PEACE OF DEATH "OPAL 0 Leawt = ET+ Dultom = DOA . <br />508 -16 -6092 b Scour eq Nom Z Rloa u. - OBw ISOP)l <br />FACILITY -No*. (1n0/AttY1XIPLpNIMiaMmnlEd/ <br />t CRY. TOWN OaW"TIONOFDEAM <br />t &SIDECRYWRS <br />p COUNTY OF OUT" <br />e <br />[Midwest Covenant Home <br />Stromsburg <br />SpcN Y4Y aNOt <br />Yes <br />Polk <br />M MKODINCE . STATE <br />IA COUNTY <br />t CRY. TOWN OR EOGiN Bo STRET AD NUMR (CAIAp ZC**j TY U BS , <br />Nebraska <br />Polk <br />rG <br />Strombu ISwb Yfi a AI <br />rg 615 E. 9th Yes <br />10 •NB•NAAB. BYGB AffahW110111l <br />ANCESTRYRIq R/(P1 AWW GRInPI MCI <br />112 AAAAMEDNEYERMAARIEO <br />117 NAME OF SPOUSE IPBd, yM+YWrteMMl <br />Ale /JlIAMyI <br />W�ste <br />Ill <br />(SPRCM <br />American tab <br />WLDOWW DIYORICEDIAM, Y1 <br />Never Married <br />-- <br />I" USUAL OCCUPATION I&W 88tl 00 WTI d" dWM aW/ <br />01 aB184t, iK Ptilt /IeY10) <br />KIND OF BUSINESS INDUSTRY <br />LJg0 <br />EI8rI1/WYaSeco10dY 10121 C081g8ItIlP 3.11 <br />,Radio Technician <br />11140 <br />Radio Station <br />2 <br />If . ATWR - NAI! WEST MODES UST <br />117 MOTHER . MAIDEN NAME FIRST MIDDLE UST <br />Abel -- Swanson <br />Esther -- Peterson <br />isWA *OECEASEDEYERIMUSMRMEDFORCEST <br />ItINFORMANT- NAME -1 MAILING ADDRESS ISTREETORRFONO- CITY ON TO" STATE.Aft <br />(VOLMaWW&I <br />OtTAarY,WOW06*FA011 w") <br />No <br />Corl ss McBeth -R.R. 2 Box 127- Stromsbur NE.6N% <br />' <br />, <br />aft BUIW "Gptimm ftwwa. <br />301 CAT <br />20C CEMETERY OR G11EWTORY -NAME 20S <br />LOCATION CRYORTOMN STATE <br />Onafoll <br />' Burial <br />Jul 30, 1990 <br />ms <br />Strobur Cemete <br />Strom burg, NE. <br />, <br />r TU/E A UCIENS6 14 Q 22 FUNERAL HOME - NAME AND ADDRESS tSTREET OR R i 0 NO C STATE. ZIII <br />e0d Z164-, A fel- Butler- Geddes 1123 W. 2nd, Grand Island, NE. <br />IEME ONLY ONE CAUSE PEA LINE TOR (al. (Dt AND ICI( - LAW V DTI~ Onsp 16V "m <br />1 Y <br />DUE TO, ORASA COWIPIENCE OF uaenral O4Tifin Wum ma 6"m <br />IaOJ L 1 <br />anZ A. <br />Due TO. OR AS A CONWW9K4 OF IAWAI W*m an0 ONO <br />S Igo Y 3 <br />OTHER WWICANT CONDITIONS - COrLW%COr &AM 10 Ofin W nA refallO <br />PART <br />12ft <br />PART III IF FEMALE WAS THEREA <br />2i AUTOPSY 21 WA. eASE REFERRED TO MEDICAL <br />B <br />PREGNANCY IN THE PAST 7 MONTHS+ <br />(SpYC Y,e d Nat EXAMINER OR COpO Al <br />viI :- No � <br />(SPIT40 y""Nori/ <br />C ! � Y b <br />A0MMI. 600. NOABCIOE. U DST. <br />DATE OP IPWAY pb D„ Yr) <br />HOUR OF INJURY 240 DESCRIBE HOW INJURY OCCURRED <br />ORPIMONOWESTR(LAWN 150"; <br />1240 <br />126C <br />u J <br />no OARJRY AT WORK 29 PLACE OF tWURY At 110),710. Idm W" Wtw, ZEO IOCAVON STREET OR R F D NO C,TV OR TOWN STATE <br />(SpOY Too III Not 0MW0406nq.*C ISOW,YI <br />2Ta DATE 00 DET IAfo O y. Y,t _ (�2U DATE SIGNED ;4A) Vfy nI•'- ..•'�� 2Qr TIME OF DEATH �w <br />• <br />e 1. - I - -- -- _ _ -- - V -- <br />S 2Tn OAie (Ib IS) ,1 27r TIYE DF DEATH 2, aaDNOUNLED DEAD rAkt [+mss r . yp ,Opphi�N^.EJ fi_AD In+i1 - <br />11/ zo 5 =• 'a M <br />276 T0M dmiL OCCWPO MJ70r�rLF irtO ptl[a aM 6wmy a 2i! On trli OLLF WA.A'+'4tL^vbd *wY'W(M ^'N OV•'c�91vomo is <br />Ca"11) 1/ Z e r* WO OW Fna PW* M10 0.0 to ea CA .40.11 f Area <br />j(( <br />i Atla tAN� �5 tlt.m va <br />_ <br />Bb OmfOdAMUSECOA&TAIDOUTFAWORGE010 708 HAS ORGAN 0A 1 NA <br />ISSUE twtION SEEN CONS W <br />IDERED, 7CD AS! ONSEN. GRANTS A' ' <br />/ <br />U Y!B :' NOANOWN Y[$ NO <br />31, MAIN AND ADDRESS OF CERTIFIER IPmvShC. COOONORSPHYSCANORCOUhTVATIORNfili •tdmmp� •J�- �•- '�"•"• �F_V•�r�� ,r...�...."" -�- <br />David Jameson M.D. 302 E. 4th, Stromsburr, NE. 68666 <br />'NYa RWiI1W1 JID J. -( •`.t, 01 I154.S, NA.. .W i0r •' <br />