|
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 />9/28/2018
<br />LINCOLN, NEBRASKA
<br />201806677
<br />ledg
<br />RUSSELL FOSLER
<br />INTERLM ASSISTANT STATE REGISTRAR
<br />DEFARTIYIENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NaRASK VVARTMENT OF HEALTH
<br />MEM} OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH 0
<br />DECEDENT—NAME FIRS • •
<br />Arther Laurence Kirk
<br />I.Male
<br />DA E r. • (Ate.. Doy. Yr.)
<br />_3. October 23, 1984
<br />1,
<br />Italian, M.•ic.w,
<br />AGE —Len Rf•thdey
<br />UNDER 1 YEAR 1 UNDER 1 DAT
<br />DATE OF RIM fMe.. Doy. Yr.)
<br />RACE-(e.pWAIN. Bieck, Aerrieon
<br />ORIGIN/DESCENT (e.g.,
<br />0e4•.i Me.) ($Muth) w
<br />('17..)
<br />MOS. i DAYS I HOLMMINS.
<br />)radian, Me.) (Specify)
<br />d. White
<br />. ` `
<br />s. American ULF
<br />so. 49
<br />e.. II M. '
<br />Y. March 16, 1935
<br />01Y AND SLATE OF PITH (tin& in U.S-A., !CITIZEN OF WHAT COUNTRY
<br />wow* easeby) !
<br />I. Hall County, Nebraska 19. U.S.A.
<br />MARRIED, NEVER MARRIED,
<br />WIDOWED. DIVORCED (Specify)
<br />io. Married
<br />NAME OF SPOUSE (Hari(•• ph* maiden name)
<br />),. L _loris C. Werth
<br />SOCIM SLFCURITY NUMBER
<br />12. 508-40-0302
<br />or
<br />USUAL OCCUPATION (Give kind of wk done dieing mat
<br />•/working life, oven if retired)
<br />Iso. Farmer .173 `
<br />KIND OF BUSINESS OR INDUSTRY
<br />13b. Farming a//
<br />COUNTY OF DEATH
<br />I,.. Hall
<br />CITY LIMITS
<br />HOSPITAL CM OTHER INSTITUTION —Howe (If net in either,
<br />IF NOW. T. k•
<br />CITY. TOWN OR LOCATION OF DEATH
<br />ub. Cairo
<br />INSIDE
<br />(Sp.cify Yes or Ne)
<br />)de. No
<br />pity .heat and Real Wail, )
<br />)cid. R.Rt. 1 Box 202
<br />11 .tom
<br />Ida.
<br />(Seedy)
<br />RESIDENCE — STATE COUNTY
<br />is.. Nebraska )sb. Hall
<br />CITY. TOWN OR LOCATION
<br />is. Cairo
<br />STREET AND NUMBER
<br />Ise. R. Rt. 1 Box 202
<br />/NODE CITY UMITS
<br />(Specify Yes or Ne)
<br />Is, No
<br />ISI
<br />in
<br />FATHER—NAME F1 MIDDLE IASI
<br />Lawrence A. Kirk
<br />MOTH lt—MAIDEN NAME FIRST MIOOIE
<br />I, Verna M. K. Kranz
<br />WAS DECEASED EVER 1P4 U.S. ARMED FORCES?
<br />No- �(N rat ~t'"' °a"' at «....1
<br />INFORMANT— NAME — RELATIONSHIP —MAIUNG ADDRESS (STREET OR I.! D. 1+0.. CITY -04. TOWN. STATE, ZIP
<br />is Kirk -Wife -R. Rt Box 202 -Cairo, NE_ ` 63824
<br />BURIAL Cremation, Removal
<br />DATE
<br />IL)elor .1
<br />CEMETERY OR CREMATORY—NAME
<br />LOCATION __" : OR TOWN STATE
<br />Burial
<br />Oct. 29, 1984
<br />20b.
<br />Zoe. Westlawn Memorial Park
<br />2Dd. Grand Island, NE.
<br />20..
<br />EAOBAWER—SFGNATURf 1 LICENSE NO. ? p o
<br />g I/
<br />FUNERAL HOME — NAME AND ADDRESS (STMET 01 CPO. No.. OTT OR TOWN. STATE, 211)
<br />—Butler —Geddes 1123 W. 2nd, Grand Island, NE.6880
<br />21.
<br />22Apfel
<br />HOUR Of OEA� IH
<br />op
<br />ii
<br />_.dr
<br />TN (Me.. Day. Yr.) //
<br />((
<br />To N CoopINsd b► --
<br />COIONIWS P$YSKIAN,
<br />w COUNTY ATTORNEY
<br />MM'
<br />DATE SIGNED (Mo. Doy. Yr.)
<br />24a. 11/1/84
<br />2db. 9:35 p.
<br />riDATE
<br />s3
<br />23e
<br />SIGNED (AN.. Day. Yr.)
<br />HOUR OF DEATH
<br />M
<br />PRONOUNCED DEAD
<br />(Mo., Doy. Yr.)
<br />244' 10/21/84
<br />PRONOUNCED DEAD(Hew)
<br />24dJ Q • 00 M
<br />23b.
<br />23c.
<br />lawellReli.w, M •P)rrl•• d'Ol% ettierati .t
<br />j
<br />•
<br />To Or ►•r .I we y kdodge d•eth .awned et
<br />mss) .et d.
<br />• ddem earl Plast and d.. t• b.
<br />br,
<br />w
<br />O. ba bre. el •i.•N•n owdyr
<br />shit taw, dem •d plea ewe Iva Do aanW
<br />2M. (Siewetum and DAN lb.
<br />234. (Siewren ad Tia.) lob
<br />_ ______ ,_ _�.____ ._...._._.... ���........ �..:.•.'..0 r.ereu.rutvr-•
<br />Yl /Tree a Print)
<br />;.1fW Aiwt!'auwrl... Vr bc.nrt.e trn.a ... • v..v..�.+.. --_ -
<br />23Stephen L. Von Riesen, Hall County Attorney
<br />imisTem
<br />20..( w•Isr.)1►
<br />;CAU
<br />P
<br />od hemorrhage
<br />DUE IA OR AS A CONSEQUENCE OF:
<br />n, gunshot wounds
<br />Grand Island. NE 68801
<br />DATE •- EIVED BY REGISTRAR (Ai... Doy. Yr.)
<br />, hare bowler. enol .d Jamb
<br />DUE TO, OR AS A CONSEQUENCE Of:
<br />PAS: OTHER- SIOP1MICANT CONDITIONS—C•wde)em c.M,ib.t*ig ti deetb bet wa r.l.etd
<br />R
<br />Acatec . wave. HOM1CIol. woe .,
<br />0e : us`')
<br />:t.mugwicid
<br />(Seedy Is..r N•)
<br />30,. no
<br />Mrr.ol ►.to•.• tweet .d de.b :.
<br />boom l b•tm•...w•e ..d death
<br />i
<br />PART IN. IF' FEMALE. WAS THERE A AUTOPSY WAS CASE REFERRED TO MEDICAL
<br />PEEGNANCT IN THE PAST 2 MONTHS, (Specify Yr or Na) EXAMN1ER OR CORONER
<br />(Specify Yr ee N•)
<br />Yas ❑ No ❑ 24.yes 29. yes
<br />CFI
<br />DATE OF M/URY (Ma. Dar, Yr.) "HOUR Op INJURY. DESCOSE NOW HUUEY OCCUR!!® de ea d was shot 1--I
<br />byState Patrol orricer w�ge p
<br />9:34pw sod. tesisting arrest
<br />tOCAno* sum 01 2.1.11 No. CTT OR TOWN STATE N
<br />W
<br />CD
<br />n6.10/23/84
<br />E Of MANY— M hew. lam, .n..$. foamy.
<br />*Pike bslldiwe. 551. (Specify)
<br />sec in yard of farm
<br />soq.Rt 1, 4. , Cairo, NE
<br />
|