|
WHEN THIS COPY CAMWES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOIWb @NPL-E_WITH (�
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS AECMN, WMTH IS \V
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _ =
<br />DATE OF ISSUANCE
<br />SEP 19 2000 COOPER
<br />ASSISTANT STATE REG/STiiAR
<br />LINCOLN, NEBRASKA 200007832 HEALTH AND HUMAN SERVICES.SYSTEA
<br />AHS -M(VS) REV. 4 -571; STATE OF NEBRASKA
<br />D22TARTMENT OF PUBLIC HEALTH, DEPARTMENT OF HEALTH
<br />�DVCATION AND WELFARE p 8(�
<br />Bureau at Vital Statistics � � 11 6 � 9 f? CJ
<br />antra NO.126...:..__ CERTIFICATE OF DEATH STATE FI, tR NO- _---
<br />.
<br />1. KAW OF SHEATH 1 1
<br />2. USUAL IMSICZWA (4Ar dos .d h d. if i+Nihd w- RrsrwwW«n alwww)
<br />B. COUNTY ' / V v
<br />M
<br />T
<br />D. . -STY. Ta x. 43 t,Lti ---'�12 N _
<br />C LF-14-ST4 Of STAY IN 16
<br />C. CITY, TOWN. ON LOCATION
<br />d, NAME or (I/ Net in hospital, on Street Ndrese)
<br />d. STREET ADDRESS
<br />HOSPITAL OR
<br />INSTITUTION f.' Fzwwi. Ho .. to
<br />rn
<br />It. IS PLACE Of DEATH INSIDE CITY LIMITS?, YE=j no[]
<br />e. IS RESIDENCE INSIDE CITY LIMITS? YES
<br />/. FARM RESIDENCE? YES
<br />N
<br />NO
<br />3. MAMt or First Middle Last A. DATE Month Day Year
<br />KCtAi[O
<br />15.
<br />�S
<br />D
<br />z
<br />108. USUAL OCCUPATION (Ciao kind a/ work done 106, KING OF BUSINESS OR INDUSTRY 11. BIRTHPLACE (,Vale or forrion country) 12 CITIZEN OF WHAT COUNTRY?
<br />drinp moot of working tile, even if retired)
<br />F Aida ` Nek -"ka U So A.
<br />_
<br />120. FATHERS NAME 11b. MOTHER S MAIDEN NAME 14. NAME OF HUSBAND OR WIFE
<br />tJ its Shriner Hazs1 3xVder Shrir►ar
<br />13. WAS DECEASED. EVER
<br />I Va. Y. sr rwkw,J
<br />IN U. S. ARMED FORCES?
<br />II/ Yr. NM ry � Ietes of •:note/
<br />M SOCIAL SECURITY NO.
<br />IT IN1'ORMANT A ddress
<br />S
<br />N
<br />•,Z
<br />ne
<br />Kra. David Shrir, Alda, Nabras"
<br />W CAUM OF DEATH [Enter only one coral per line Jer (a), (0), and (c).1
<br />-
<br />CZ),
<br />N
<br />ONSET AND DEATH
<br />!!$MEDtATE CAUSE (a)
<br />j
<br />c) t
<br />Which pars r to
<br />aDeer nrx fat.
<br />slating the under-
<br />lying Corse law DUE TO (e)
<br />PART U OTHER %NWK:ANT CONDITKRIS CORTMWTRIC TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE PART Ill. IF FEMALE, WAS THERE A
<br />19, WAS AUTOPSY
<br />C-
<br />CONDITION N RI PMT I PREGNANCY M THE PAST 3 MONTHS?
<br />PERFORMED?
<br />_3
<br />A=
<br />r
<br />e YES ❑ owe
<br />YES ❑
<br />Me. ACCIDENT SUICIDE NOMKIDf
<br />_
<br />ZOD. DE iBE HOW INJURY OCCURRED (Enter mature a /injrry in Part I or Part t! a /4rm M.)
<br />10 a O
<br />20t TIME OF ffqy� Month. Deg, Year V -�
<br />INJURY
<br />• 7 0 P. M.
<br />:71
<br />rTj
<br />,
<br />f --r -3
<br />rr
<br />O
<br />c
<br />21 1 ateended the deesased from to ' - •~ 44 And last Saw alive on
<br />m
<br />Death occurred at on on the data stated above; and to the best of mwlwddo, from the causes stated.
<br />22s. ( or title)
<br />220. NESS 22e. DATE SIGN[9
<br />C"
<br />C?
<br />O
<br />NEMOY (SperIft)
<br />'�A ��tim
<br />21. DATE RECD AY ISBUISTRAN 2S. NEiPiTRAR'S S UR[ / . 2i NAM? OF MORTUARY ADDRESS
<br />�� Idr� Grand 1lsnd* �.
<br />�
<br />o
<br />to
<br />r =�
<br />CD
<br />2
<br />-;
<br />D
<br />r I>
<br />U;
<br />co
<br />W
<br />I
<br />U)
<br />C1a
<br />N
<br />c�
<br />WHEN THIS COPY CAMWES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOIWb @NPL-E_WITH (�
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS AECMN, WMTH IS \V
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _ =
<br />DATE OF ISSUANCE
<br />SEP 19 2000 COOPER
<br />ASSISTANT STATE REG/STiiAR
<br />LINCOLN, NEBRASKA 200007832 HEALTH AND HUMAN SERVICES.SYSTEA
<br />AHS -M(VS) REV. 4 -571; STATE OF NEBRASKA
<br />D22TARTMENT OF PUBLIC HEALTH, DEPARTMENT OF HEALTH
<br />�DVCATION AND WELFARE p 8(�
<br />Bureau at Vital Statistics � � 11 6 � 9 f? CJ
<br />antra NO.126...:..__ CERTIFICATE OF DEATH STATE FI, tR NO- _---
<br />.
<br />1. KAW OF SHEATH 1 1
<br />2. USUAL IMSICZWA (4Ar dos .d h d. if i+Nihd w- RrsrwwW«n alwww)
<br />B. COUNTY ' / V v
<br />0. STATE D. COUNTY
<br />D. . -STY. Ta x. 43 t,Lti ---'�12 N _
<br />C LF-14-ST4 Of STAY IN 16
<br />C. CITY, TOWN. ON LOCATION
<br />d, NAME or (I/ Net in hospital, on Street Ndrese)
<br />d. STREET ADDRESS
<br />HOSPITAL OR
<br />INSTITUTION f.' Fzwwi. Ho .. to
<br />Rd 1 Route #1
<br />It. IS PLACE Of DEATH INSIDE CITY LIMITS?, YE=j no[]
<br />e. IS RESIDENCE INSIDE CITY LIMITS? YES
<br />/. FARM RESIDENCE? YES
<br />N
<br />NO
<br />3. MAMt or First Middle Last A. DATE Month Day Year
<br />KCtAi[O
<br />15.
<br />OF {� L L
<br />(?jpt or print)
<br />Shri rwr - DEATH F 19"
<br />t
<br />SEX 6 COLOR OR RACE T MARRIED 11 NEVER MARRIED ❑ B DATE OF BIRTH 9 AGE (In pearl IF UNC[R I TEAR UMOER
<br />♦
<br />WIDOWED ❑ DIVORCED OCU 2 1 ZZ loot AbtAdeg) xe.IA• Des. Harr x....
<br />108. USUAL OCCUPATION (Ciao kind a/ work done 106, KING OF BUSINESS OR INDUSTRY 11. BIRTHPLACE (,Vale or forrion country) 12 CITIZEN OF WHAT COUNTRY?
<br />drinp moot of working tile, even if retired)
<br />F Aida ` Nek -"ka U So A.
<br />_
<br />120. FATHERS NAME 11b. MOTHER S MAIDEN NAME 14. NAME OF HUSBAND OR WIFE
<br />tJ its Shriner Hazs1 3xVder Shrir►ar
<br />13. WAS DECEASED. EVER
<br />I Va. Y. sr rwkw,J
<br />IN U. S. ARMED FORCES?
<br />II/ Yr. NM ry � Ietes of •:note/
<br />M SOCIAL SECURITY NO.
<br />IT IN1'ORMANT A ddress
<br />nsr
<br />•,Z
<br />ne
<br />Kra. David Shrir, Alda, Nabras"
<br />W CAUM OF DEATH [Enter only one coral per line Jer (a), (0), and (c).1
<br />INTERVAL BETWEEN
<br />PART 1. DEATH WAS CAUSED BY-
<br />ONSET AND DEATH
<br />!!$MEDtATE CAUSE (a)
<br />j
<br />Conditi 'Ju ,
<br />ng, DUE TO (0)
<br />Which pars r to
<br />aDeer nrx fat.
<br />slating the under-
<br />lying Corse law DUE TO (e)
<br />PART U OTHER %NWK:ANT CONDITKRIS CORTMWTRIC TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE PART Ill. IF FEMALE, WAS THERE A
<br />19, WAS AUTOPSY
<br />CONDITION N RI PMT I PREGNANCY M THE PAST 3 MONTHS?
<br />PERFORMED?
<br />_3
<br />A=
<br />r
<br />e YES ❑ owe
<br />YES ❑
<br />Me. ACCIDENT SUICIDE NOMKIDf
<br />_
<br />ZOD. DE iBE HOW INJURY OCCURRED (Enter mature a /injrry in Part I or Part t! a /4rm M.)
<br />10 a O
<br />20t TIME OF ffqy� Month. Deg, Year V -�
<br />INJURY
<br />• 7 0 P. M.
<br />20d. INJURY OCCURRED Me. PLACE OF INJURY (e. p., M or shot/ home, W/. CITY. TOWN, OR LOCATION ,. ODUNTY STATE
<br />B?HILE AT O HOT WHILE ►m, /sdory, otrtd, o,Ofct at de.)
<br />WORK AT W0 3K 0
<br />c
<br />21 1 ateended the deesased from to ' - •~ 44 And last Saw alive on
<br />m
<br />Death occurred at on on the data stated above; and to the best of mwlwddo, from the causes stated.
<br />22s. ( or title)
<br />220. NESS 22e. DATE SIGN[9
<br />23s CREMATION• 230 DATE 2k. NAME OF CEMETERY OR CREMATORY 23d. LOCATION (CUg, town. or county) (,Yale)
<br />NEMOY (SperIft)
<br />'�A ��tim
<br />21. DATE RECD AY ISBUISTRAN 2S. NEiPiTRAR'S S UR[ / . 2i NAM? OF MORTUARY ADDRESS
<br />�� Idr� Grand 1lsnd* �.
<br />�
<br />LEGAL: The Northwest Quarter of the Northeast ouarter (NV7kNEk) and the Fast
<br />Half of the Northeast Quarter (E�NEk) of Section one (1) , Township Ten (10)
<br />North, Ranee Eleven (11) G1est of the 6th P.M., in Hall County, Nebraska
<br />
|