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7 <br />t. <br />OECEDENT- <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANDJIUMAN SERVICES <br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. a -a <br />DATE OF ISSUANCE <br />SEP 1 2 2005 <br />LINCOLN, NEBRASKA <br />Q Q C- <br />2 U 1 8 0 7 7 0 ASSISTANT ST RE Ia1 R R - <br />HEALTH AND HUMAN SERVICES SYSTEM <br />ATTAIN OFP AMA -3i ?A T+OEMAiMAND ili!w4SIIRYIC!'.iI %!4OE <br />MAL STAY <br />CERTIFI£ATh OF DEATH - <br />,,3 03310 <br />T <br />WALE LAST 2 SU a DATE OP DEATH Nemec 0. Wed <br />William Don <br />A. CITY APOSTATE OF OWN //ARAN USA AeNedAAP1W <br />Chamberlain South Dakota <br />T SOCIAL SECURITY MAMA <br />5 8-0512 <br />a FACERS. Nem 3etowMekeot EDOSI IIne«a11�r1 <br />Galen <br />Ss AGE • LAM Sse14q UNDO; <br />(Wu 50 SIDS DAYS Sc. NOUNS TAWS <br />6 <br />isls ew.ACEOF DEATH <br />�ji NC PITAL 1.2 ....- <br />1 ❑ T31 GIAT!TC .., <br />. F ncis Medical Center 1 0 coA <br />Id CR" TOWN DA LOCAT"CH OF DEATH j 4e WSCE CITY S.M1r S i A. ( .PITY OF DEATH <br />r8Sk,_ I Yea E 11n 0 Haji <br />lob CONN i 15e UTv TOWN O:T:0CATa01; Os STREET AND NUMBER Itx+uciroIv CX#9 <br />I ',rack* E - , . , T 1 <br />7 <br />10 - Ky..eaq WOO Aalglep MOW tt. 010:041/Pt 5e{. OM¢t. ?AMOK Now* cite t2. E"1 S1ARRtEO <br />.10:130, berl 0005:4 1.3 <br />He USUAL ORATION IGne&NSWewe abet " German <br />a&wawa*Ma*AM11risk rem ' t� AtlJITC>>r1 PIESSStli�C6T.g3' <br />Postal Contract Carrier <br />M FAIt/Elt - :UAW - - <br />M NES - STATE' <br />OTHER: 0 Nunng NOM <br />❑ RAarinee <br />000, iSpocA, <br />Q WAS DECEASED EVER 51 US. MOOED FORCES? <br />!rise no or wok) in on see..r calMAs% el weests <br />meat <br />T <br />Tee 1NFO R M T SWAG ADDRESS <br />3e INSIDE aTv i. TS <br />' <br />` Yes J1515°EJ <br />MOWED IS NAME OF SPOUSE ie Het oweritn new* <br />I N£VEP <br />WORM) <br />ED <br />. T SSOTSSSN <br />tga bar-CANEST NAME <br />1 Joyce G. Laden <br />IST Et/ OP RF 0 N0. C., -re 015 TOWK SATE 2TPJ <br />-ye <br />ROOST <br />Joyce G. Gruber <br />15 EDUCATION !S4c4Te'irootE 3000=0pe$•5 <br />Mande <br />Fiow.ry SecsndenN 0 521 <br />12 <br />WADDLE <br />Cos.{. n.Aw,•, <br />MAVEN S UM A R <br />Baker <br />2707 W. 4th Street Grand Island. Nebraska 68803 <br />20 ESIBAU: ER - S50NAT(ARE is LKENSE NO 2t a 41154;$ OF °670'. T{fs , 25a DATE I! gat CEMETERY CR CRESM1 ONY NAME <br />Not Embalmed ❑ D Rs... sN (March 22. 2003! entra �TE <br />224 FUMFSRAL /TORE - NAME 1 ale CaletERY OA CRENATOMh' LOCA qa Ciiv ON TWA pr STATE <br />Apfel-Butler -Geddes <br />229 FUNERA_t <br />ROTAS•; ADDRESS ISTREETORRF.D. NO CITY OR TOWN STATEN'S <br />1123 West Second Street. Grand Island, Nebraska 68801 <br />PART APABSLAX <br />CAUSE INTER ONLY ONE CAUSE PFR LINE FIN: wibS. AMD ILII <br />yy�.� <br />rlet/tri 0"/k <br />lal <br />DUE TO. OR AS A CQNSEO'IE}CE GF <br />DUE SO. OR AS A CO:SEOUENCE OF <br />Gibbon. Nebraska <br />Welvel 5.Myen ones/ aro dear <br />.eIYaI te111ee %01/11 and amen . <br />.WVY Omens onset and osor <br />OTHER SIC S&X*SNT CONDITIONS • - <br />PARI C4ctmalrti 1i wine As... OSA na nFadd I PREGNANCY W THE PAST 3 MONTHS/ WAS CASE REFERRED TOEXAER OR CORONER' <br />24 AUT Y 25SYN <br />' IAUIT t0-Sa) Yee i1 NO . NO MI ❑ . Ni <br />24. 230 DATE OF 4Atilr /Art. Db; rNt tee HOUR OF !LAMP 9I:i$et CcSCR:BE 1aQW.W..JRY OCCURRED <br />la <br />G Small 0 P>' 25a 54 5.235 AT WORK i 2Ma �1H oRT t �y _ Meet win 26g. LOCATION STREET OR A F.D. NO CITY OR TOWN STATE <br />L1P....os i.g.g.K. I Yee D NO Q i s�c3i <br />27a GATE OF 0e A.04, AM 011.r, <br />25. DATE SIGNED ISM Dar r.I <br />2 3l'•I,4,3 i <br />s <br />2Tb Oak SIGNED y, M +Jes PH i 2Te Rae GF DEATH i tee PRONOUNCED DEAOiAM L. n I <br />3/o,a%t3 t 1 €,t' <br />1 r M <br />1 27 To me nee ac my •^aA.niown xa'l. a1At NV due and dm to Ta <br />CMtxisl NlYed. : -.-. i�f'j <br />i yT tt <br />and Tee 9 , I -_----•--- e i� - <br />i 2e 010 TOBACCO USE CONT w DEATH'+ <br />� T����?7f� }�3Da HAS . � -. OR Tt$$uE <br />L YES L.J NO /i••7 :I/ANOVA I -`'--- <br />i <br />31 NAME AMD ADDRESS OF CURVIER IPHYSIavrt CORQNEPS PNY$Y�AM OR cOL04TY ATTORNEY. , TNM a Pawn <br />Rae TIME OF DEATH <br />M <br />2154 PPYNOUIICED DEAD Moue <br />2!e Co Pte WAN 4 SYlSW Seen and or 154.4541014 ni ny some 5.eY. =wise r <br />-�' <br />tie 1,0*. PIN and Owe and to.w mutest g$sd. <br />end Tee <br />0014*TION SEEN CONSIDERED/ 30.b WAS CONSENT GRANTED/ <br />YEi <br />M <br />Pr. -Jeff re K. Kin 729 N -••th Custer: Grand Island NEbraska 68803 <br />320 DATE PILED DY REGISTRAR Rit Dar n / <br />NC <br />0 NES <br />l:J NO <br />320. REGISTRAR <br />__ _MAR 2 5 2003 <br />