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<br />Ieif9llA� 1'r. I
<br />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 />6/27/2019
<br />LINCOLN, NEBRASKA
<br />201903899
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH 0 3 7.4 2
<br />19
<br />1 Of •:!. CENT NAME F•R.• 'WOOLF LAST
<br />Arlone Luella Breiner
<br />2 'lEA
<br />Female
<br />3 DOTE OF DEn's,tA,n. '60
<br />December--& 2003
<br />A CO Y APOSTATE O. 510'.. r'r,.•u,SJ ootp [MMI
<br />58. AGE Lau DrRATay
<br />UNOEORI YEAR
<br />UNDER' DA0
<br />6 DATE OF (OMR Mom, D 18.1,
<br />Hazard, Nebraska
<br />Y.,, 64
<br />ISY MO$ DAYS
<br />x HOUR. MINS
<br />June 23, 1939
<br />T SOCIAL SECRTIY NUMBER
<br />5.;ia-50-1648
<br />ea PLACE OF DEATH
<br />HOSPITAL ■ 1,41 em 0I .R
<br />❑ ER Ovma/IH
<br />0 DOA
<br />© .—n4.. --
<br />■ R.S•Je0ce
<br />■ �� P '
<br />so FA',0..:0.0•,,0 ' ,Y #' oo V"e.:: Yels'eneronl
<br />St. Francis Memorial Health Center
<br />et CItY TOWN OR LOCA'•DR :OF DEATH
<br />Grand Island
<br />e0 NSIDE
<br />Y=:
<br />CITY LIMITS
<br />© No
<br />■
<br />8, COUNTY CF DEATH
<br />Hall
<br />9a RESIDENCE STATE 90 COUNTY I 9 CITY. TOWN OR LOCATION
<br />Nebraska Hall I Grand Island
<br />90 STREET AND NUMBER I, .,og LO Ca. h va51DE CITY L'SF'S
<br />2320 N. Sherman 68803 Yee EXJ NC 0
<br />'D PACE ie q. WNp BM.• A-,p.can Ylrta^ - II ANCESTRY :eq Italian M°ncOq.GMnan. ekl
<br />"R1r$OeCi,fhite SDe Mi American
<br />12
<br />A. ..A sa.^�A*e
<br />I[�' MARRIED ■ WIDOWED ! 13 NAME OF SPOUSE rra
<br />Hi
<br />NEVp
<br />• MARERIED ripvOOCEv I Glen M. Breiner
<br />-oo a°e ,U'4M
<br />•Aa JSUAL OCC'>ATICN 1.511 And d.0,0 dem nu g.o Ian KIND OF BUSINESS INDUSTRY 5 EDUCATION ,Soc'I rMT gNCi
<br />01./r+g Ole eve. Areeve. r-" EN^rury r C '2: COYACe .
<br />I
<br />Homemaker I Domestic 12
<br />54 FATHER -NAME FIRST 1100LE UST 17 MOTHER FIRST +POOLE MAIDEN SURNAME
<br />Henry D. Smith Minnie Brewer
<br />10 WAS DECEASED EVER IN U 5 ARMED FORCES' I '5a INFORMANT NAME
<br />Pres -< 0' oral I a .es 0 ,0 ea. W. Ra'e5 d Serowe
<br />NoI ( Glen Breiner
<br />194 WEORMANT MAILING ADDRESS ' 5TREET OR R F D NO. CITY DR TOWN STATE 21111
<br />2320 North Sherman Grand Island, NE 68803
<br />20 EMBALMER- 51GNA, AES ICENSNO
<br />moi,
<br />OF
<br />I( 4(j227
<br />21a ME'.N000FD
<br />Es B.y
<br />FY- SPOST1210 DATE 2,c CEMETERY ON CREMA I DR. NAME
<br />■ FknR a Dec. E, 2003 I West lawn Memorial Park
<br />22a 'USERAO. 0CAAE. NAME
<br />Apf;el-Butler-Geddes
<br />: 21C CEMETERY OR CREMATORY LOCATION p'. O0 TOWN STATE
<br />■ ^ ❑ ,I Grand Island, Nebraska
<br />225 FUNERAS. HOME ADORESS 151 REST OR RSD NO. CITY Oil TOWN STATE ZIP)
<br />1123 West Second, Grand Island, NE. 68801
<br />23 ItVECM'E CA;;SE 'ENTER ONLY ONE CAUSE PER LINE FOP a..0, AND:0/: - Mir :a 0N6eena a, v47
<br />N C f- S 'v L C,Q f.Qt N ccs- �-� �tcJ
<br />_ E TO OR A5 A CONSCOuENCE OF axe --:a: Re..en cps. a4' rov
<br />CAI E TO OR AS A CONSEEY /ENCE OF
<br />CI
<br />MI9..015H.een RYSPI Ane. -ear
<br />OTHER SIGNIFCANT CONDITIONS . Ltnotons:U.enEumg n me Ream dA 601 ,64.0
<br />RAPT
<br />PART lb :F FEMALE vas THERE A ! 1= ALITOPSr 75 WAS CAic PEFERREO IG MEDICAL
<br />PREGNANCY INT a AS 3!AOSTHS' EXAARNER OR COFNJNEK'
<br />�y.Y! [1:44/-
<br />-''T t ��
<br />I...:Agee '750. Yes fl NR I I les r 1101 � Yes fl No Llr1'
<br />".da DATE OF INJURY 1440 DNF Yr1 126c7.01480F 06,21• 260 72€SCAICA NNN:.000 CCuRREO
<br />!�I u
<br />LI 6.441e El_ 110.0,0 126e I00URY AT W0W1 1261 PLACE OFINWRY .AIny'. ta.." sr..n•envy
<br />:Ya DATE OF DEATC. .AA Dar Yr)
<br />12/5/03
<br />27° DAYS SIGNED :A4 Dar 0,I
<br />12 /8
<br />2:0 ',me Ye. d Kew Akar
<br />.asses. 5,000
<br />A0 Toe/ IP
<br />USE '.ONTR/SVTE TOME DEATH'^
<br />YES 0 NO ` UNKNOWN
<br />1:19 a.m.
<br />0iM at RWa sed 8R se ea
<br />1
<br />7010 LOC•TIC,
<br />STREET OR R F D NO
<br />CITY OR :O'WN
<br />hGERIE SA •NEO .5k .+.• 1246 IME OF DEATH
<br />STATE
<br />26c >RON:?UNCED DEA_ aa: LA Y., 200 PRONOUNCED DEAD
<br />M
<br />I ter. 0' Y'e OUR Cl 0-0003 a, ce 06e61g040% m m, 00000 Ream 0[0111300 a1
<br />N'e Rao an' p000 )'IR 0 .10 TI0 Ra115e's: SlalO
<br />'SgYRre a -a Tae. la
<br />HAS ORGAN OR TISSUEsD0NATONBEEN C `SOERED' 1770 WAS CONSENT GRANTED'
<br />NC 0 YES
<br />68803
<br />0 YES
<br />31 NAME ANO AOORE550F CERT,:IER IPHY51dAN.CORONER S SCAN GO COUNTS ATTORNEY Y,pIO F+Y
<br />Sitki Copur M.D. 2116
<br />324 PHl1TRAP
<br />st Faid ey Ave., Grand Island, NE
<br />1325 DATEFLEDLITREGISTRAR14u
<br />DEC 1 nO3
<br />CD
<br />U-1
<br />C)
<br />W
<br />
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