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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 />2.01806678
<br />RUSSELL FOSLER
<br />IlNTEREVI ASSISTA1NT STATE REGISTRAR
<br />DEPARTMENT OF H I1 ALTH
<br />AND HITIVIAN SERVICES
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH
<br />Bureau of Vital Stutisties
<br />CERTIFICATE OF DEATHS ‘ 20
<br />70 0880T
<br />1TATE ru! Humana
<br />"DECEASED -NAME F113T
<br />1. VERN
<br />M1001E LAST
<br />M. KTRK
<br />SEx
<br />2. Female
<br />DATE OF DEATH 1 MONTH, OAT, TEA!)
<br />3- AuigUat 16.. 1970
<br />RACE wen. NEG*O, AMERICAN INDIAN,
<br />AGE -LAST
<br />UNDER 1 YEAR
<br />4MDER 1 DAY <
<br />DATE OF -BIRTH I DOWN, DAT,
<br />COUNTY OF DEATH
<br />EEC. I VIVIFY I
<br />1;;, White
<br />BIRTHDAY (YEARS!
<br />s.. 57
<br />MOS.
<br />so.
<br />DAYS:
<br />HOLDS
<br />s1.
<br />i MRN.
<br />SIM:1
<br />danuary 14 1913•
<br />Adams
<br />CITY, TOWN, OR LOCATION OF DEATH
<br />AL n 1e; d
<br />NMI cm LIMITS
<br />( SPECIFY TES OR 440 1
<br />n. ;.
<br />HOSPITAL OR OTHER INSTITUT
<br />74. :: - I • •
<br />-NAME I1r NOT IN EITHER, GIVE you AHD NUM1E11
<br />1 -Vter
<br />STATE OF METH (N NOT IN U.S.A., NAME
<br />COUNTRY;
<br />1. Wisconsin
<br />CmZBN OF WHAT COUNTRY
<br />T- U.S.A.
<br />MARRIED, NEVER • ED,
<br />WIDOWED, DIVORCED I SPECIFY I
<br />n. Married
<br />SURVIVING SPOUSE 114 wire, own 114I004 SPAM 1
<br />11. Lawrence Kirk
<br />SOCIAL SECURITY NUMBER
<br />12. 505-44-3683
<br />USUAL OCCUPATION (GIVE KIND 0
<br />WORRING LIFE, NEN IF RETIRED 1
<br />wife
<br />I2•. HouslaTy.
<br />WORK DON! 0(41140 MOST OF
<br />KIND Of BUSINESS OR INDUSTRY
<br />121. Dnmpet3DENCE-snoe
<br />Nebrraska
<br />COUNTY TOWN, OR
<br />1._
<br />Hall Cai rn
<br />tOCAAON
<br />1«4101 cm Lw114 TREET AND NUMBERSPCIFY TES01 NO)4.
<br />144. _ _
<br />R
<br />FATHER—NAME FIRST DI47
<br />/ '^-� '/�
<br />LAST MOTHER -MA DEN NAME FISH MODI! LAST
<br />.. IIS. Q . I. •
<br />/i
<br />INFORMANT -NAME --RELATIONSHIP
<br />1h': - • • '. • I., . 1 . - • -
<br />KING ADDRESS ISTSEET OR R.F.D. NO., Cm OR TOWN, SITE, ZIP/
<br />IA. .'• _ • - 1 - • _ . .
<br />PART I. DEATH WAS CAUSED BY: (ENTER ONLY ONE CAUSE PER LINE MR ;o), (b), AND (c))1nAEEN
<br />4014417 I DAL
<br />TH
<br />I1. 1MM101ATE CAUSE
<br />(MIacCicr €arn!
<br />0 trinut•"ia
<br />CONDITIONS, I AID,
<br />(MIDI to C SI 1,
<br />CADS!
<br />(b► Generalized arteriosclerosis.
<br />Few years.
<br />STATINAT!
<br />STATING TSE ASDlR-
<br />411-
<br />IY�Nfi CAUSE LAZY
<br />.
<br />OUE TO, OR AS A CONSEQUENCE OF:
<br />(4)
<br />PAST R. OTHER SIONIHCAMT CONDITIONS, CONDITIONS CONTRIBUTING -TO DEATH OUT NOT RELATED
<br />co CAUSE GIVEN IN PART Ro)Schizophrenic _ react ion, chronic
<br />undif f rren -ted type.
<br />?ART I1 14 MEAIME, WAS THERE A
<br />PREGNANCY IN THE PAST 3 MDNTHSW
<br />YES 0 140 ❑
<br />AUTOPSY
<br />I n; 01 14141
<br />"• No
<br />IF YES wits HNO14*0* cow
<br />110![!0 14 Oe7ERMININO CAUSE
<br />IN 0lATM _
<br />ACCIDENT, SUICIDE, HOMJCIDE,
<br />OR UNDETERMINED tow n )
<br />DA I (MONTH, DAY, TEAS 1
<br />214.
<br />HOUR
<br />21(. Al.
<br />HOW INJURY OCCURRED (DN1en samosa or SAWED IN PART 1 on PART It (LAM 11)
<br />Mt
<br />INJURY AT W
<br />( 44e077 VES OR NO!
<br />/LACE Of
<br />°MICE MDG
<br />INJURY AT HOW, MEM, STREET, rAC7017,
<br />,ETC. I SPEC'FY I
<br />LOCATION ( Bran 01 R.E.D. 140., an 01 TOWN, STATE 1
<br />ler
<br />CBTTITKATRQN— 140.0H DAT T1AR MONTH DAT TEM
<br />PHYSICIAN: TO
<br />I Arrow') 714
<br />EE
<br />21,, 010EA5ED. WR0 ! _ - 121b. 8 16 70
<br />AND IAST SAW 14441/1111 ALIVE 044
<br />mownDAT YEN
<br />211. 8 16 70
<br />1010/010 NOT 7(11 THE
<br />1007 AFI414 DEATH.
<br />t74. DID
<br />DEATH OCCURRED :4.7 INR PUCE, ON THE
<br />(NOm4 ;OAR, ANO, TO 111! ow
<br />` OF. M7 KNOWLEDGE, DUI
<br />24.91 zu aMTO THE CAWSEISI SI1t0.
<br />CERTIFICATION -MEDICAL EXAMINER OR CORONER: 04 THE .ASIS Or IRR HOUR 0 DEATH
<br />E1AAIK/ATION OF 111E ND04 AM0/01 714! INVESTIGATION, IN M7 OPINION,
<br />EDAM OCCURRED ON RN DATE AND DU! 70 174E CAUSIISI STATED.
<br />ffi. M
<br />SHO "CM"' WAS FRONOUNCID DEAD
<br />LLO4TH DAY YEAR HOU*
<br />M.
<br />CER INER-NAME Inn OR nRNA SIGN E f i acne 0a MCI
<br />2a. Sors±e + ea.-116-ILTA-
<br />DATE SIGNED memos, Dm, row
<br />n_ueust 28..1970
<br />MAIL SS+•-CERTIfIER SHEET OR R.F;O: - -.-Mi OR N SITE ZIP
<br />Tl
<br />BURIJII, CREMATION, REMOVAL
<br />INKrn , %
<br />24.. ALJ
<br />CEMETERY OR CREMATORY—NAME
<br />l %
<br />2414. _. � , ' 4' _ • r,
<br />t 11 • onoR IOwN 57*11
<br />r /
<br />2Ec. .0 i / i I
<br />0 (MONTH, DAY, TRA.)
<br />_
<br />FUNERAL HOME.,,N 4 A.! ADDRESS 7 37 OR R,r.°.• , C177 01 TOWN, s7A11, En) / .0,
<br />EMBAUAE j rung/a E CENSE NO. j� / i
<br />,256. , F e ,7. ' 4 Tia /�
<br />REGIS — AZURE /� N.
<br />144 �K.t J ff . , AA .Y �`�L /(/�% i D lti
<br />A ,-r, •', I. ISM*
<br />1411. �71)
<br />
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