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<br />DAYS HOVR3 . MtNS E
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<br />.. �lihite
<br />American 6,.
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<br />CITY AND A CM tIRE1t E net iw Y.S.A., ...
<br />CITIZEN OF WHAT COUNTRY.
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<br />Nebraska
<br />U.S.A.
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<br />Ut1TT NYMBE! :.
<br />tiwAt OCCUPATION (Gi.. kiwd .I Berk dew. deriep wed
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<br />COUNTr OE DEATH
<br />09 -5085
<br />c�
<br />O --4
<br />,.e. Hall
<br />f�1
<br />INSIDE f17Y L1MtTS
<br />HOSPITAL OR OTME R INSTITUTION - Newe ([F ne[ i. eilk(Seer'
<br />R
<br />Y.,«Ne)
<br />1es
<br />9iw and
<br />s'land Memorial Hosp
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<br />and Island
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<br />N
<br />„e
<br />-STATE
<br />COUNTY CITY, TOWN OR LOCATION
<br />STREET AND NUMBER
<br />NSIDE CSTY LIMITS
<br />Hall 1,s<. Grand Island
<br />2608 W. Stolley Park
<br />r
<br />raska
<br />CD
<br />,�
<br />FIRST MIDDLE LAST
<br />MOTHER - MAIDEN NAME FIRST MIDDLE LAS
<br />tFATHtit-mouta
<br />I Peter W. Kolbo
<br />IN
<br />WAS DECEASED EVER IN U.S. ARMED FORCES?
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<br />�T
<br />`'
<br />u: No
<br />a
<br />SURIAL,Cnwatiow, DATE
<br />CEMETERY OR CREMATORY -NAME.
<br />LOCATION CITY OR TOWN STATE
<br />17, 1985
<br />-,
<br />m.. Bur al zSept.
<br />7a. Island Cemetery
<br />Tod. Grand Island, Nebraska_
<br />CD
<br />zlpfel- Butler - Geddes 1123 W. 2nd, Grand Island, NE.68801
<br />A E ( Yr.) DATE SIGNED (Me. Der, Yr.) HOW OF DEATH
<br />g7>o September 13, 1985 =YO
<br />71a. 74b. M
<br />•> DATE IGNED(Ale -, DOT, Yr.) HOUR OF DEATH !zt ►RONOUNC ED DEAD PRONOUNCED DEAD (H—)
<br />i (M°.. DoP: rr.)
<br />736. 1:51 p , -2
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<br />REGISTRAR
<br />DATE REC 1WO BY REGISTRAR (Me., Day. Yr.)
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<br />260. mq et.wl� GG J C.
<br />766. . ��. IIK3
<br />77. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (,)) ✓ Iw.e.,•1 b.1.•.. ew-1 .wd dwM
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<br />IN, If tEMALE. WAS TNIII A AUTOPSY
<br />IN THE PAST 3 A%OHINST (SP-Hr
<br />,WAS CASt RE /IttEO TO MEDKAI
<br />T- « Me) [IIAMINER OR CORONtt
<br />II
<br />Yes ❑ Ne 0 7B.
<br />y�SP -:(r r« « NO
<br />No 111. No
<br />•tnuNr, swutx. NoArcla, uaoeT ,
<br />DATE a Iwun (Ale., o... ►..) Now a Iwutr
<br />Now Iwun OCCURRED
<br />-�3
<br />103,0Kd7”
<br />30e.
<br />306. ]Oe. M
<br />IMPUAV AT WORK
<br />"Pse" T. «NN
<br />130.
<br />PLACE OF rtPUtT - A. been. ..ee«. 1r.
<br />.Mio i 'Id(.P. •l.. (SIN.4)
<br />-
<br />IOC•TION StRttT W t F B. N•" CM' OR TOWN STATE
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<br />WHEN THIS COPY CAMWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM R CERTIFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAI$¢TlGS:ECTIEAlf� WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. -
<br />DATE OF ISSUANCE
<br />SEP 14 2000 = iAXWY*;V60PER
<br />ASSIS Al *FNW04YRAR
<br />LINCOLN, NEBRASKA HEALTH AM HUMAN SERWCE&SftTEM
<br />ta0007918
<br />STWIT W NEE MKA -0Q U MM of XMrn
<br />CERTIFICATE OF DEATH , ! W
<br />-MAME �D OF D"T" (M... Dew
<br />rt.TAp Bavmonfi 1Kvlbo - - (, :Sale 1_Sentember 13_ 19RS
<br />0^CE- (e.f.. WNRe. Mac>< Awe.iRw
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<br />OER ) TEA3 uNDER t DAY DATE OF {KTM S�Yr,)
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<br />69
<br />DAYS HOVR3 . MtNS E
<br />e ��. �, Jan. 22,
<br />.. �lihite
<br />American 6,.
<br />1916
<br />CITY AND A CM tIRE1t E net iw Y.S.A., ...
<br />CITIZEN OF WHAT COUNTRY.
<br />MAtR1E0, NEY'Et MANtfD,
<br />PtitRE OP ShOUSE (K e+h. fiw widen wew,.)
<br />Nebraska
<br />U.S.A.
<br />WIDOWED, orwW ID (SP09dr)
<br />Married
<br />, Vlair
<br />,
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<br />10,
<br />Ut1TT NYMBE! :.
<br />tiwAt OCCUPATION (Gi.. kiwd .I Berk dew. deriep wed
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<br />COUNTr OE DEATH
<br />09 -5085
<br />IKIMDOfIU5'mtssoe"40USTRT
<br />.P- ..ki.,a(......:(..«..d)
<br />fie- Carpenter �7?
<br />e�r�
<br />T3b. Construction C
<br />,.e. Hall
<br />Ot LOCATION.OF MATH
<br />INSIDE f17Y L1MtTS
<br />HOSPITAL OR OTME R INSTITUTION - Newe ([F ne[ i. eilk(Seer'
<br />Y.,«Ne)
<br />1es
<br />9iw and
<br />s'land Memorial Hosp
<br />Ewer. Room
<br />and Island
<br />,x.
<br />14d_ and
<br />„e
<br />-STATE
<br />COUNTY CITY, TOWN OR LOCATION
<br />STREET AND NUMBER
<br />NSIDE CSTY LIMITS
<br />Hall 1,s<. Grand Island
<br />2608 W. Stolley Park
<br />1(.Sp- "ie s°" " °'
<br />raska
<br />,
<br />,�
<br />FIRST MIDDLE LAST
<br />MOTHER - MAIDEN NAME FIRST MIDDLE LAS
<br />tFATHtit-mouta
<br />I Peter W. Kolbo
<br />117 Alta - -- De re
<br />WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />I INFORMANT -NAME - RELATIONSHIP- MAILING ADDRESS (STK[T Ott T 0 NO CITr 44t rq.vN SnT[, iFTT
<br />'e
<br />(T... ,.. « •..It to ne. a..• •......d d«., d .e...r•)
<br />, b 8t5 o j
<br />Wife -2608 W. Stolley Park Rd. -Grand Islan
<br />u: No
<br />„.Angela.Kolbo-
<br />SURIAL,Cnwatiow, DATE
<br />CEMETERY OR CREMATORY -NAME.
<br />LOCATION CITY OR TOWN STATE
<br />17, 1985
<br />m.. Bur al zSept.
<br />7a. Island Cemetery
<br />Tod. Grand Island, Nebraska_
<br />_Grand
<br />EMBA ATURE i LIC SE NO. ,2 Q FUNERAL HOME -NAME AND ADDRESS (STREET CN 111.0. NO., CITY a TOWN. STATE, 71ry
<br />zlpfel- Butler - Geddes 1123 W. 2nd, Grand Island, NE.68801
<br />A E ( Yr.) DATE SIGNED (Me. Der, Yr.) HOW OF DEATH
<br />g7>o September 13, 1985 =YO
<br />71a. 74b. M
<br />•> DATE IGNED(Ale -, DOT, Yr.) HOUR OF DEATH !zt ►RONOUNC ED DEAD PRONOUNCED DEAD (H—)
<br />i (M°.. DoP: rr.)
<br />736. 1:51 p , -2
<br />,�,� M
<br />1•Me b+M � r 24d, M
<br />cew.(e, 4e.MdPw d..1► « M. 1iwr, de wd P • ewd d.. On o• ►e, •/ iw •n p.w.ew d.eM -c «.•d «
<br />•
<br />• « = 1be Fw», d.1• MI pl «• e.d dw ti M• .e...(,) ..eMd
<br />3d,(UP —..d PAN) � N'T. 74.. (S.P.«,r. •.d 1.N.)
<br />NAM ANO ADDRE OF fItTTFlE� :. •.. SSC' •• CO T W R PHYSICIAN a VI COUNTY ATTORNE rpo e, Irinq
<br />Dale Kemmerer M.D. Grand Island Memorial Hospital, Grand Island, NE. 68801
<br />REGISTRAR
<br />DATE REC 1WO BY REGISTRAR (Me., Day. Yr.)
<br />"T/' =-
<br />� ,,-
<br />/ �
<br />260. mq et.wl� GG J C.
<br />766. . ��. IIK3
<br />77. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (,)) ✓ Iw.e.,•1 b.1.•.. ew-1 .wd dwM
<br />PART ! r
<br />i.) C-1e . tL/�- - _� +i�I kA U fo .1 _
<br />- -
<br />�T� AS A C NSEOUENCE OF: Iw1.n•1 ►•1�.« .w-1 . M d•.M
<br />AI
<br />DUE TO, OR AS A CONSEQUENCE OF: lefenel b•ree•w .w.•1 ..d d.eM
<br />Id
<br />PART ANT C S -C• dmv 1softii linq N d.•M W1 wet rN•Nd ►ART
<br />PRIGNA14CT
<br />IN, If tEMALE. WAS TNIII A AUTOPSY
<br />IN THE PAST 3 A%OHINST (SP-Hr
<br />,WAS CASt RE /IttEO TO MEDKAI
<br />T- « Me) [IIAMINER OR CORONtt
<br />II
<br />Yes ❑ Ne 0 7B.
<br />y�SP -:(r r« « NO
<br />No 111. No
<br />•tnuNr, swutx. NoArcla, uaoeT ,
<br />DATE a Iwun (Ale., o... ►..) Now a Iwutr
<br />Now Iwun OCCURRED
<br />OR ►ENoR.O IWISTIGATION. (5,...[,)
<br />103,0Kd7”
<br />30e.
<br />306. ]Oe. M
<br />IMPUAV AT WORK
<br />"Pse" T. «NN
<br />130.
<br />PLACE OF rtPUtT - A. been. ..ee«. 1r.
<br />.Mio i 'Id(.P. •l.. (SIN.4)
<br />-
<br />IOC•TION StRttT W t F B. N•" CM' OR TOWN STATE
<br />DESCRIPTION: The West Twelve and Fifty -Eight Hundredths Feet
<br />((12 581) of Lot g e (7) and the East Fifty -Eight and Eighty -Five
<br />lundredths Feet (� .95 }, f T.(,r F; ohr (R) in wP -- r Snal tc- .irhITI t7.
<br />1,
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