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200007926 nn: T I'a7 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT VITAL STATISTICS CERTIFICATE OF DEATH .Z W 0 W U W 0 U. 0 W Q Z of C) -- - __ nFr EDFIIT , NAIIF fln t IAIDOI F 1_A51 2 SF% 7 OATE OF DEATH rMnnrh flew Pearl - Ivan Harold Sjoholm Male September 20, 1998 [711 --- -- ---- - -- - ---- - -- -'- - .. . AND SIA IF nl RII+I11 ll I'r Il A mn rcl lr yl Sn A(.F 1...1 P�nhA.y UNDERI YEAR UNDER DAY I R DALE Ot BIRTH AMnM Day YM.1 IV . I sh MOST nnv5 Sr HOUnS MINS Courtland, Kansas 87 February 24, 1911 7 5nr lnl SFCUR11r NilrAnFn -___ R. n1 ACE Of nFA1H • 520 -05 -1670 HOSPITAL I'V1111", OTHER © No•,, -.w1 m - . - . - - - Ah -[ Ar —III V - I.—n. -- --- - - a n.rl �nel,luhr qvn M - - -- � FR DUtPeI1.nI ❑ RAenrP Community Care ❑ DOA ❑ ahe.ISPPfh R• 1;11v TOWN On 1 Or,A WIN OF OFATII -_ _._ ^ - - - - -- -- RA INSIDF CIIYLIMITS RR COUNTY OF OFATN - --- Grand Island Y.. LEI No Hall I -[] 9. nFSIOFNCF S7TF 9h CnIJNIV 9C n17V iOWNORLOCATIrN STPEETANONUMSFn rin iutonplq Cm*o oe'NSIDECITYtIVIS j9d Nebraska Hall Grand Island_ 1915 S. Arthur Y., ® N. ❑ 10 .,:f log WI'n. ALIT Amo¢.n I-l-, ANCFS/nr Ieq hell- Me- on,German, e1Cl 12 FjMAnnIED (-j WIDOWED NAMEOFSPOUSE rn wly &1,# maMe.r namgl III 113 t�i�t1 So•oNl SpeuWl - - - -- �J NEVER L J DIVORCED e zerican MAR, Adrienne Mahone 14. USUALOCCUPAIION .G „ <bnd n /gYr.A AMP memo mnp -- - tnr wr�l ^e nrP. earn �rref�<rn Fle-e nr M Sq<ond.ry 10,121 College T1.a m 4•I _ Manager Lumber IR rnlr+FR. NMAF--- _---- -finST --------- MInnIF I.ASI t; M0111FR FInSf MIDDLE MAIDEN sun"AME John Albert Sjoholm I Hilma Rosene Ill VIA' DECEASED FVEP IN US ARMED FOnCES> 1g. INFORMANT NAMF IYes - n Unk 1 III yes It- w.r ..d d.tn 1 a.r e-1 7Tb DATE SIGNED rMI� rl. vr! 27C IIMF OF DEATH 2:25 PM Yes _ 1 -3 -42 to 10 -3 -45 WWII Adrienne Sjoholm — 77d to the Mato my YrmwlnAgn de.lh nccun0d 1411hq TIP. dnln and PLcR d AuP In the A= ranonlsl "gTPA L �-' I” twOnMAIlF FAIR ING AnnnFSS Cl TnFF.7 on n FO NO CITY OR TOWN STAIF ZIPI 1 S. Art r, Grand Island, Nebraska 68801 78e On me basis d esmmatlon snd a nveaugenon, m ^IY olrnlon Aeam "ccw•.A Tn the I -mo . daq end place end Aue M the Ceo.Nal staled 20 FrARnI 'SIGNA IURFA ICFNRE 21. METHODOF DISPOSITION 21b DATE 21c CEMETERY OR CREMATORY NAME ISl nature end Idle) ► .. I I .. .� " __ - -- -- - FAnl.l ❑n.mnyAl 9 -23 -98 Ft. McPherson National S- e WW Tiff fllllFRAI H M N IAF- 71A CEMETERY OR CRFIAATORV IOCATInN - - -- CITY On TOWN STATE 30a HAS ORGAN OR 11SSUF nONATQNJB�EEjN CONSIDERED' ❑ YES pr'j NO Livin stop- Sondermann F.H. ❑aem " " "" ❑nn " "' "' Maxwell, Nebraska YI r IAIAFANOADDR ESSOFCEpnFIERIPHV51C1At1CORO tlEnsrT4YSICtANORCO (INTYAtTORNFYI T Prmn 2c WILLIAM J LANDIS MI) 2444 W FAIDLFY 6?ff ID ISLAND NE 69,903 ------------- - - - - -- - - - - -- 27b FUNERAL HOME AnORFSS ISTRFET OR RF D NO CITY On TOWN STATE, 21PI 32h DATE FILED BY REGISTRAR IPM Oav Yrl -- 601 North Webb Road, Grand Island, Nebraska 68803 IMMEDIATE CAUSE IENTFR ONLY ON AUSF PFn IJNE FOR I.1 Ih). AND (ell 1 Ime'.1 Llehyeen . ^n n. a'• PART 1' Cie. t 1 I \ X 1 lel v F;_i�_ lc_. t. Z i K h C�'\ 113 DUE TO OR AS A COIISF.OUFNCF OF — I InMr .I t`7 only ene q.• I Ibl D' IF TO OR AS A CONSFOUENCE Of -' I Ime'Y.1EehFeen • IT - - PART OT HFR SIGNIFICANT PONnGIOHS - COnAOTna [enl.ibtAing In nrF1'Q nol Te aC 11 _ 1 ' -I , �; v.tl V .� I L I -^ .� „r'.- ,r. `( L _'� 1 RI 111 IF FEMALE. WAS THERE A GNANCY IN THE PAST J MONTNS> (Ages 10 SA) Ysa No 1 74 AUTOPSY C Vee Je WAS CASE REFERRED TO MFDICAL 1.11 ( EXAMINER OR CORONER Yp No 25a Nth DA I OF INJURY (Mn (1.V Yr.J 2RC HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED A-dgnt U IJ "APt..mned M r7 7 u SIYrI I. CJ P•Mmq Nn,.,..... I,,.n egapn, 2140 IN.. TRY AT WORK Yes u NU ❑- 71e PLAC�(IF INJURV -Al Raple. Itlre, ". ". Incom o c0 wAinq eM. l pPnr Y 2E0, LOCATION STREET OR RFD NO CITY OR TOWN S7TF —_- —_ -- — 27. DAIF OF DEATH iAA1 llnv Vrl 214. DALE SIGNED IM, Dal lr l 281, TIME OF DEATH �S SEPTEMBER 20, 1998 a M 7Tb DATE SIGNED rMI� rl. vr! 27C IIMF OF DEATH 2:25 PM 214, PRONOUNCED DEAD .AM Day. Yrl 2140 PRONOUNf ED DEAD I", 77d to the Mato my YrmwlnAgn de.lh nccun0d 1411hq TIP. dnln and PLcR d AuP In the A= ranonlsl "gTPA L �-' s ? .� r M 78e On me basis d esmmatlon snd a nveaugenon, m ^IY olrnlon Aeam "ccw•.A Tn the I -mo . daq end place end Aue M the Ceo.Nal staled ISl nature end Idle) ► .. I I .. .� " S- e WW Tiff .__i.' 111 DID TOBACCO USF COIITRIBI/TE TO THE DEATH' )C IFS U NO ❑ 1111KNOWN 30a HAS ORGAN OR 11SSUF nONATQNJB�EEjN CONSIDERED' ❑ YES pr'j NO 30 b WAS CONSENT GRANTED' x ❑ YES ® NO YI r IAIAFANOADDR ESSOFCEpnFIERIPHV51C1At1CORO tlEnsrT4YSICtANORCO (INTYAtTORNFYI T Prmn 2c WILLIAM J LANDIS MI) 2444 W FAIDLFY 6?ff ID ISLAND NE 69,903 ------------- - - - - -- - - - - -- 17A Rf GISTPAR - -- 32h DATE FILED BY REGISTRAR IPM Oav Yrl -- FOR VITAL STATISTICS USE ONLY ;lu "o, C01y Of tr2 original i , n&P6 o� C.tuo� -t �1?U Iii illy' j;fE °� ao of a0,-,6 7__ ==Z Notary Public 111 GENERAL NOTgRy_State TERRY Of Nebraska MY Comm. fxp OSO.t -HEN