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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 />5/7/2019
<br />LINCOLN, NEBRASKA
<br />201902770
<br />2.4
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND IIUMAN SERVICES
<br />STATE OF NEBRASKA—DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />78
<br />13886
<br />DECEDENT–NAME FIRST MIDDLE LAST
<br />I L^7 AL BRUCEHARDER
<br />SEX
<br />2Maee
<br />DATE OF DEATH (Mo., Day, Yr.)
<br />,. Die 3 1978
<br />RACE–(e.g., While, Black, American
<br />ORIGIN/DESCENT (e. s., Italian, Mexican,
<br />ACE–:act ainhaoy i UNOZR 1 YEAR UNDER I DAY
<br />)DATE OF BIRTH (Mo., De y, Yr.)
<br />Indianerc.)f$aecify)
<br />.
<br />German, tc.) Spgcify) cc
<br />s.!�m?Jt4-Can
<br />(Try.)
<br />6a 59
<br />MOS. : DAYS HOURS : MINS.
<br />db. 4,
<br />1
<br />y. Feb . 26. 1919
<br />CITY AND STATE OF BIRTH Of not in U.S.A.,
<br />name sou
<br />B dif6ott, Nebnarska
<br />CITIZEN OF WHAT COUNTRY
<br />g. U.S.A.,D_
<br />MARRIED, NEVER MARRIED,
<br />WIDOWED, DIVARC O (Specify)
<br />MarVEked
<br />?TAME OF SPOUSE (If
<br />„_ Atbenta
<br />a ih, give,waidea name):
<br />FhanC.iAca
<br />SOCIAL SECURITY NUMBER USUAL OCCUPATION (Give :iaa. Nn. work done during most
<br />'USUAL
<br />vrorking even ILretired �(-.2
<br />,� SOk-01-k369 ,,, my ton ��anageh
<br />KIND Qf� B SINESS RRIDUSTRY
<br />f1jQ jai[ (7Q,a
<br />am,. Company
<br />COUNTY OF DEATH
<br />��p
<br />,.a. Ha,L2 Coun.tg
<br />CITY. TOWN OR LOCATION Of DEATH
<br />f, [
<br />Ghand I,.12and
<br />INSIDE CITY LIMITS
<br />�A,es a)
<br />bk. ezorN
<br />HOSPITAL OR OTHER INSTITUTION –Name (If not in either,
<br />give . WOJ Memo4o1 Not J�t
<br />144.
<br />IF HOP. OR INST, Indiaee DOA.
<br />Oapatient/E..er.:M.. Inpatient.: (Specify/
<br />Inpatient
<br />RESIDENCE–STATE
<br />Nebhcca a
<br />COUNTY�/^ �➢
<br />1Sb. Hall
<br />CITY, TOWN OR LOCATION
<br />MSc. G�and T 4and
<br />STREET AND NUMBER
<br />,Sd. 1027 N. Sherman
<br />INSIDE CITY UNITS
<br />IN YyYou a.No)
<br />(SIse.
<br />,ae,5
<br />FATHER–NAME FIRST MIDDLE LAST
<br />„ John C. Hatden
<br />MOTHER–MAIDEN NAME FIRST MIDDLE LAST
<br />„ A2v�na --- Lachanmacheit'
<br />WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />cri;i. 7nt)1(1, ,3°„ 12dda,w4,�.m„.,E.
<br />Zlp
<br />INFORMANT—NAME—RELATIONSHIP—MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR ?miry.
<br />,m . Atbenta NaAde4-WJie-1027 N. Shulman-G'tan.d C14Lc.Jd;NF.
<br />BURIAL,. Cremation, Removal
<br />, ' Staiat
<br />DATE L//CC C. C v
<br />20b. 1978
<br />978
<br />CEMETERY OR CREMATORY–NAME
<br />20c. G'tand ',stand Ceenetvcy
<br />LOCATION CITY OR TOWN STATE
<br />_ 20d. Grand Land, Nebna.4ka
<br />EMB
<br />_ zt.
<br />SIGNATUR & UCENSE NO. a/ 7
<br />� /
<br />FUNERAL HOME NAME AND ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP)
<br />F �e.E-6-Geddeb: 1123 W . 2nd . Grand I.atand, NE. 68801
<br />• Ike ofAri.(41time e end pI e is due to IM
<br />stoNd / '�
<br />ed
<br />230. (Signed.... and Tit10 X
<br />it
<br />a:<
<br />vYA
<br />:=K
<br />L'iC
<br />'Jilla
<br />`Yr.) 0 8
<br />to -d.,
<br />a., p
<br />On to bode of uoininonon and/or in.whgaaan, ,n rtryopinion deoM occurred of
<br />the time date and place and due is Me coir(.) .toed.
<br />240.(Signature and lid./
<br />Ts b. C•11101•11
<br />Ahem/lna PNY$
<br />°"IV
<br />DATE SIGNED (Mo., Day, Yr.)
<br />2Z�. Z�/i'%/.
<br />N • R Of DEA?
<br />23.. ( 2 Al.M
<br />' 7L Pr
<br />DATE SIGNED (Mo. Day, Yr.)
<br />246.
<br />HOUR Of DEATH
<br />24c. M
<br />DATE Of DEATH (Ma., Day,Yr.)
<br />27d f
<br />PRONOUNCED DEAD
<br />Day, Yr.)
<br />24 24d.
<br />PRONOUNCED DEAD (Hoar)
<br />24e. M
<br />NAME AND DIES S Of CERTIFIER (PHYSICIAN, CORONER'S PHYS(CLTN OR COUNTY ATTORNEY) (Type or Print)
<br />25 A. F. Van Wi.e M).1). 7 7 W. Anna Grand ',stand, NebitaisFza 68801
<br />REGISTRAR
<br />DATE It El jED BY REGISTRAR (Mo., Day, Yr.)
<br />27. IMMEDIATE CAUL— r (!VIER Of Lt OII .AUSE PER11NE FOR (a), (b), AND (c))
<br />PART
<br />DUTO, OR AS A CONSEQUENCE OF: u
<br />(b)
<br />I Servo) ierwann anwr and deo*
<br />;.ack.ci-citq? t -n , Lt
<br />Interval between onset and deet
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(.1 -`
<br />-TT N(. IF FEMALE. WAS THERE A AUTOPSY
<br />NtEGNANCY IN THE MST 3 MONTHS? f rr Fy Yw No)
<br />YM O No 0 12B.
<br />, marvel between onwr and deet L
<br />L
<br />) -
<br />WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER
<br />(Spwify TN No)
<br />29. F.
<br />PART OTHERSIGNIfKANT CONDITIONS —Conditions contributing :, deet buy aw. ,:=i=->
<br />II4or
<br />ACCIDENT, SUICIDE. HOMICIDE, UNDE1.,
<br />OR PENDING INVESTIGATION_ (Spw.fy)
<br />DATE Of INJURY (Me., Day, Yr.)
<br />SOb.
<br />HOUR OF INJURY
<br />SOc. A4
<br />DESCRIBE HOW INJURY OCCURRED
<br />]Del.
<br />L30a.
<br />INJURY AT WOK _
<br />(Specify. Yoe or Nal °
<br />�Oe.
<br />PlACE Of
<br />elfin. building,
<br />SOf.
<br />NJUR?— Al hem, fans. crrwt,: Ioctory,
<br />etc. (SpociIyl
<br />LOCATION STREET OR R.F.O. No CITY OR TOWN" STATE
<br />�Og.
<br />
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