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Q z M Ir- 11 f 3 r c� rTT cn © r ca o sT� ch co NO The East Half (E' /z) of Section Twenty -two (22), Township Twelve (12) North, Range Twelve (12) West of the 6`h P.M., Hall County, Nebraska Excepting a certain tract more particularly described in Deed recorded in Book 77, Page 640 and Excepting a certain tract more particularly described in Deed recorded as Document No. 96- 100643. 2QQ�(� Am. 11W sTA. or..AjKA• vw a7A �f of HaAl.TB AND Hw. smtvx= f+n Amm A!D surmn 129%02 vff'AL SfATlsM CERMCATE OF DEATH O C O O V C 0 0 V O 4) C E W X V z Z W p c W 10 U W 0. U. O a W � 0 Z Li 4 0 Pauline M. DeSoe X 'fit ~ c� (In M 5b Moe DAYS C= 7 SOGILL SECURTIV NUMBER f) 0 z r f` x n c.) -+ r*'I o Be COUNTY OF DEATH Omaha Y« :K N. ❑ ouglas N RESIDENCE -STATE Q z M Ir- 11 f 3 r c� rTT cn © r ca o sT� ch co NO The East Half (E' /z) of Section Twenty -two (22), Township Twelve (12) North, Range Twelve (12) West of the 6`h P.M., Hall County, Nebraska Excepting a certain tract more particularly described in Deed recorded in Book 77, Page 640 and Excepting a certain tract more particularly described in Deed recorded as Document No. 96- 100643. 2QQ�(� Am. 11W sTA. or..AjKA• vw a7A �f of HaAl.TB AND Hw. smtvx= f+n Amm A!D surmn 129%02 vff'AL SfATlsM CERMCATE OF DEATH O C O O V C 0 0 V O 4) C E W X V z Z W p c W 10 U W 0. U. O a W � 0 Z Li 1 DECEDENT -NAME FIRST MIDDLE LAST 0 Pauline M. DeSoe X 'fit ~ c� (In "'\ 5b Moe DAYS C= 7 SOGILL SECURTIV NUMBER n = U Swe1« ❑ Pw4wv = . ❑ ER Clnpabara ® Rast«nte x 6818 S. 145th St. c.) -+ r*'I o Be COUNTY OF DEATH Omaha Y« :K N. ❑ ouglas N RESIDENCE -STATE 9b. COUNTY C4 QI 9d. STREET AND NUMBER lncAKM9Ip coca/ Co _n O Douglas Omaha co ❑ 4M Y«:El Na 10 RACE - la.p.. Whole Black Anoncan Yrd1w1 Q z M Ir- 11 f 3 r c� rTT cn © r ca o sT� ch co NO The East Half (E' /z) of Section Twenty -two (22), Township Twelve (12) North, Range Twelve (12) West of the 6`h P.M., Hall County, Nebraska Excepting a certain tract more particularly described in Deed recorded in Book 77, Page 640 and Excepting a certain tract more particularly described in Deed recorded as Document No. 96- 100643. 2QQ�(� Am. 11W sTA. or..AjKA• vw a7A �f of HaAl.TB AND Hw. smtvx= f+n Amm A!D surmn 129%02 vff'AL SfATlsM CERMCATE OF DEATH O C O O V C 0 0 V O 4) C E W X V z Z W p c W 10 U W 0. U. O a W � 0 Z Li 23 IMMEDIATE CAUSE IEN1tH OMIT vest cAU5b YtH Late nUh lal. Iw. Am ICI( PART � nom/ / J, �1 D_.0 01. 2ZW r«rvw awwwn a..r.o aaan ILtl 1cl 1 DECEDENT -NAME FIRST MIDDLE LAST 2 SEX 3 DATE OF DEATH rMar.n DIaY Yaart Pauline M. DeSoe Female Jun 16 0 24 AUTOPSY PIPPIN 4. CRY MID STA OF M h U.SA. vela 4ale.Y1 IAp« 10-541 Y« Nd Y« No Cairo, NE 1Wa.1 86 5b Moe DAYS 5c. HOURS MRS Jan 12 1915 7 SOGILL SECURTIV NUMBER M PLACE OF DEATH U Swe1« ❑ Pw4wv HOSPITAL ❑ kNlaewe OTHER ❑ Nura N HOlne . ❑ ER Clnpabara ® Rast«nte 11 b FACILITY - Name /O w-A%te n. 9^^e 9aeer and —owl 6818 S. 145th St. ❑ DOA ❑ Darr Ispecdw & CITY TOWN OR LOCATION OF DEATH 60 INSIDE cRV l9ARS Be COUNTY OF DEATH Omaha Y« :K N. ❑ ouglas N RESIDENCE -STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER lncAKM9Ip coca/ 9• NSIDE CRY LIMITS NE Douglas Omaha 6818 S. 145th St. ❑ 4M Y«:El Na 10 RACE - la.p.. Whole Black Anoncan Yrd1w1 1I. ANCESTRY (0-g.. aaaan. M«rcw1. Gomm. act t2. ❑MARRIED ® WIDOWED 13 NAME OF SPOUSE /a-de pwa madan Anal �•. c= ° -,.. i•'xi'.3. v (sw owl aR-�! ari can 11 NEVER DIVORCED MARRIED and TMa 14& . USUAL OCCUPATION IG" kAd de.crA dna drop /noa/ 14b KIND OF BUSINESS INDUSTRY 1 15 EDUCATION ISpauN drel' "hoon Vad4 cwVlalad) aSolowdary 10 -121 11 v5.1 "" cir d wonrrq Mr. aH1nrneeradl Clerk Department Store 16 FATHER - NAME FIRST MIDDLE LAST IN,r MOTHER FIRST MIDDLE MAIDEN SURNAME 117 Carl Stoeger Luella Pryor 16 WAS DECEASED EVER IN US. ARMED FORCES? '190-. INFORMANT -NAME ndor 1raLl If Y «."war am dalaa d w wool Steven DeSoe 19b INFORMANT MAILING ADDRESS (STREET OR R.F.D NO.. CRY OR TOWN. STATE, 21P1 6818 S. 145th St. Omaha, NE 68137 20 . E TUBE • LICENSE NO. 21a METHODOFOISPOSI'TION 21b. DATE 21c, CEMETERY OR CREMATORY NAaE • k - ., ro• ❑ Rwal Jun 20 2001 ' Cairo Cemetery . . FUNERAL HOPE -NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Boyd E. Braman Mortuary ❑ G lan ❑ DarlaW Cairo NE 22b FUNERAL HOME ADDRESS (STREET OR F F.D. NO.. CRY OR TOWN, STATE 21P1 1702 N. 72nd St., Omaha, NE 68114 a 23 IMMEDIATE CAUSE IEN1tH OMIT vest cAU5b YtH Late nUh lal. Iw. Am ICI( PART � nom/ / J, �1 D_.0 01. 2ZW r«rvw awwwn a..r.o aaan ILtl 1cl PART OTHER S*WCANT CONDITIONS - COWN9 s cdr ftA g b OW OMM &A na1 ralwatl PART W IF FEMALE. WAS THERE A PREGNANCY IN THE PAST 3 MONTHS 24 AUTOPSY 25 WAS CASE REFERRED TO AEDICAL E%AMNER_ OR COMMONEM a IAp« 10-541 Y« Nd Y« No Y« Na 269 260. GATE OF 96KNRY /Aep. Q0-/'. Yrl HOUR OF 91JURY DESCRIBE HOW INJURY OCCURRED _ .. ❑ AeCdha ❑ LXdMmrlaO 126c [29d. M U Swe1« ❑ Pw4wv 260- tI U AT WORK 261 =LLrRY ;N _ , lum. aasal. hdo y 26q LOCATION STREET OR R.F D NO. CRY OR TOWN STATE ❑ Hp K d0- aw""OW Y« ❑ NO ❑ 270- DATE OF DEATH No Day. Yr/ 260-. DATE SIGNED /Aft. Day. n / 26b TIME OF DEATH /(0 21a�19 a a 270. ATE SKiNED plb.. Day. Yr.) 27c TIME OF DEATH 29c. PRONOUNCED DEAD /Ab.. Dry. Yrj 269 PRONOUNCED DEAD ~I 4M 11211 v ss 270- At Ills bat d my tmw4de - �cwr arrla. wes arld 0-e b !1e ;; -- ? 2Be. On ale b«9 d aaamnaaon arW a rlvsngawn. my ap..on osae+ occurtW ■ arc Ana. dale and place 0-M d,e b 0-r ca•.selsl anted. ISj and TMa DID.TOP4C6. , DS"4 1' L 71we'� NO ❑ 30A HAS ORGAN OR TISSUE DONATION BEEN ❑ YES M CONSIDERED? w0 30.b WAS CONSENT GRANTED? ❑ YES NO �K� -M NO 31 NA:1C ...::S Ca kN t., ER S PHYSC AN OR COUNTY ATTORNEY( ?yy9 n Prod `" ( 7 u �o (o s � t/<c a �`• t DATE FLED BY REGISTRAR Aft. Dry. Yr) 32a ISYAAR JUN Thyu certifies thl.b, document to be a true copy of an original record on file with Vital Statistics, Dou92:s County Health Department, Omaha, Nebraska. Certified copies must have a raised seal in the area to the left. Reproductions of this green certificate are not legal copies. Date issued: JUN 2 2 2001 Registrar Return to: Respeliers & Harmon, P.C. , P.O. Box 4519, Omaha, Nebraska 68104 CCD 9 >Ct. 2� c* co 4 KA. (may