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<br />3 STATE OF NEBRASKA > a13i
<br />�+`I1"` W(rM�; IrtiyN;lne
<br />$er5rpyrr,ss ?64NI17,(((IDasawa ,.•>�;�MdAh)`x at�:�4E664Y{a((11V`!DS ry s ,µrya �I �5��
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<br />WHEN I' THIS COPY CARRIES THE RAISED SEAL OF THE 'STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE ` A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />12/16/2019
<br />LINCOLN, NEBRASKA
<br />DECEDENT NAME
<br />I.
<br />2()f9O799
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OFIIEIRA$ItA-r OEPA*TMENT OF HEALTH
<br />• , MAW OF V TAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />FIRST
<br />MIDDIE
<br />LAST
<br />Raymond Robertson
<br />RACE -l._.. wNi#. BIack A...iean ORIGIN/DESCENT
<br />lnd:ew. (e.4..11e1)en.M..ieaw.
<br />-4J (Sp.d4)
<br />4.
<br />o
<br />Rio
<br />AGE-I..Rinbd.,
<br />G« -an. sic.) (Spwfy) (Yrs.) MOS. DAYS I HOURS : MINS.
<br />White I3. erican .a. �. r
<br />awn AND STATE OF aH (NN . is U.S.A., CITIZEN Of WHAT COUNTRY MARY D NEPER MARRIED, ' NAME Of SPOUSE (NriF., give maiden none)
<br />4108.0 cwaky) IVADOwto DIYORCED(Specify)
<br />11^�"ie( i 11. Shelia i• jlexter
<br />XINDiC)FRUSINESS OR INDUSTRY COUNTY Of DEATH
<br />SEX
<br />2 Male
<br />DATE OF DEATH (Me.. DoT. Yr.)
<br />3February 20. 1981
<br />DATE Of BIRTH (MD.. Day. Ti.)
<br />,.Aug, 29. 1947
<br />UNDER 1 YEAR UNDER 1 DAY
<br />R.aIsland. Ne. 9. USA IR
<br />SOCIA: J NUMBER USUAL OCCUPATION (Give kind of work dene during sees(
<br />of working life, .won if refired)
<br />12.) 08-54-3190 13.. Truck Driver ,X1( 4
<br />CITY, TOWN OR LOCATION Of DEATH INSIDE CITY LIMITS
<br />IIa. arsnrl Ts) and
<br />RESIDENCE -STATE
<br />COUNTY
<br />`Ila. IENeb-A p FIRST ISb.
<br />FATr
<br />lib
<br />„tae 11 ii 11 iam A
<br />DECEASED EVER IN U.S. ARMED FORCES?
<br />(V... e.... vee) ( (n yes. pee re. sod daft, e/ were)
<br />b. IS. No
<br />/UREAL, C'xal.atIee, Removol
<br />204. Burial
<br />EMRALi 2*-S14NATURE S UCENSfjNO. 244O
<br />.•
<br />Yeo
<br />DATE OF DEATH Mie., Day, Yr.)
<br />(Specify Yes Of No)
<br />14..
<br />DATE
<br />eb. 23, 1981
<br />23'a.
<br />DATE SIGNED (MO, Day. Yr.)
<br />IsbAmerican Freight
<br />HOSPITAL OR OTHER INSTITUTION -Name (N net in .iM.r,
<br />give drest and ,Maker)
<br />es ,1id.1423 N. WaTh t St.
<br />CITY, TOWN OR LOCATION
<br />134.
<br />14e. Hail
<br />STREET AND NUMBER
<br />Grd 1 lnd 1�. 1421 N. Walnut
<br />MIT 12004E11: -MAT NAMEFIRST
<br />If NOSP. OE INST. Wks*
<br />colpeoveotroo. Sin, I.4eIwe (Sporey)
<br />MIDDLE
<br />INSIDE CITY LIMITS
<br />(Switch Yoe or N.)
<br />is.. X es
<br />MIDDLELAST
<br />Robertson i tr. Barbara. Taal).
<br />le
<br />Keck NAME-^#ELATSON$Ni►-!?RAILING ADDRESSCI (STREET OR R.I.D. NO.. YOR TOWN.(P)
<br />�STATE. V
<br />19. ShP1tale
<br />. K_ i?nbrtann yji fA-1 93 N. Wan
<br />lYiiie!'Ca8n8ei1'IMinna
<br />CEMETERY OR CREMATORY - NAME LOCATION CITY OR TOWN STATE '
<br />20e.Grand Island (City) Grand Island NN
<br />FUNERAL HOME -NAME AND ADDRESS (UNIT 02 :.'..6. NC. GTT OR TOWN. STATE. YN;,'
<br />22. Livingston-Sonderman1's,505 W.Koenig, Grand Island,Ne,
<br />HOUR Of DEATH
<br />DATE SIGNED (Mo. Day. Yr.)
<br />/it
<br />244, 3/3181
<br />,.
<br />z PRONOUNCED DEAD
<br />23b. (Mo., Day. Yr.)
<br />Tv, beef toy dee* •11t11/•1111 Ow Noe. Mee ova pier* eve die e 24e. 2/
<br />2 0/R1
<br />the basis Nae dere Awl i.dmoM afw24d.
<br />I HOUR OF DEATH
<br />24bunkno4ljfl
<br />PRONOUNCED DEAD (Hoed
<br />23..
<br />.(3ioeievt cajTAW Oil' u 24s.S,peWn end fide)
<br />NAME AND ADDRESS Of CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OSATTORNEY) (Type COUNTY ( or prim)
<br />Stephen L. Von
<br />#GISTRAR
<br />Riesen,
<br />11 _15 a_ M
<br />kedotizA
<br />Co.. Attorney, P. 0. Box 367, GrandEIsland,Ne. 6880
<br />..s •,9 .. D .SID SY R TRAIL (Mo.. Do,. Yr.)
<br />244.(Sieeet.,.)1114
<br />V. IMMEDIATE .CAUSE '" (ENTER ONLY ONE CAUSE PER UNE FOR (a), (6). AND (c))
<br />PART
<br />,., suicide
<br />DUE TO. OR AS A CONSEQUENCE Of:
<br />p, gun shot wound to head
<br />DUE TO. Of AS A CONSEQUENCE Of:
<br />(c)
<br />PART QTJT!! T51GHIPICANT cgNomoms-Ceaditiene conteb.$ieg e, deed bel eel (NA
<br />II
<br />ACCIDENT. SuiCilif. HOMICIRE. UNDET., DATE Of [POLITY (MA. Oaf. Tr.)
<br />OS PENDM(i NVESTIOAT1ON. (Specify)
<br />1.bide aDb.
<br />*QUO AT M/DR[ PIACI 4P 011/JIT- ANA*.
<br />(Specify Tel er IM) *41k. bei4dieg. e,c. (Specify)
<br />30e. no 305. home
<br />Mime' bemire meet ear ANA
<br />instantaneous
<br />MN"' bei win, eed dean•'
<br />•
<br />•Nene? baa.. mom sad IA
<br />PART IN. If TENAII. WAS THELE A AUTOPSY WAS CASE RNERRRD TO
<br />PREGNANCY .M THE PAST 3M011TNST (Specify Ter .r Ne) STAMMER OR CDIDNER
<br />Y« Q No 2g. yes29.
<br />Specify Ter ..N.)
<br />NOW Of INJURY
<br />unknown M soa
<br />LOCATION
<br />Of KIM 1402 041 OCCURRED
<br />
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