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�r <br />AM <br />VM THIS COPY CARRIES THE RAISED SEAL OF THE NEBUSIKA STATE <br />DEPARTKMT OF HEALTH, IT CERTIFIES THE BELOW TO BE.A-TRVVt"DOPY <br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPAMONT -&--; HEALTH <br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEFOSiTORt-Wk <br />VITAL RECORDS. <br />DATE OF ISSUANCE <br />AUS30 SW STANLEY S. - CWPER <br />LINCOLN, NEBRASKA BTJ•FAU, OF VITA1. TATISTICS <br />p <br />104879 SUMO$UM <br />V MOF VMWOMLH <br />COMFICATE OF.DEATH '5 89 06030 <br />Fvw mom LAP <br />a s" <br />OFOEAT" <br />Hilda Amelia Shipman , <br />Female <br />I Hay., 22, 1989 <br />4cM* *STA'rEOFSvrfH NaWPUSA.l aft"W <br />5&-AGF- Lap " - <br />30 <br />6,.C&'E OF MTN JW^ OW Y&W <br />00S. DAYS <br />r <br />M.A. & <br />NeT-Ack County, Nebraska <br />"�6 <br />April 5, 1913 <br />57D *L . .10, v "OEM <br />2p 0 ER'O0wfiw&- 0 OCA <br />11, <br />384-12-233P <br />a -X.wwffw. 7.0- wMaw mvow <br />5- C-F TOWN Oil LONTMOT Not <br />O2 tXSID2CTY U05 <br />"I"Crow) <br />"Mes <br />B&COUMOPBOUR- <br />St. Medical Center <br />Grand Island, NE. <br />Hall <br />IL FWMi0i" - STATE <br />. I <br />a COUNTY <br />OR EIGZATrim WSTREETAXONUMSER (MOVZVOMM <br />'Island <br />iA fts"Cm UwT3 <br />Mw ro CrAw <br />Sel k zaska <br />Hall <br />Grand R.R.1 Box 230 <br />14 PAM <br />AWASTRY"j,1IWc &MMI3"MAn <br />J;z IM1iQRE0JIEYER aWURIEO. <br />13 NAME OF SPOUSE (9 a'* pre nWw MW <br />I1111- <br />"�'ft"American <br />Albert J. Shiv='—Z"- <br />wtit <br />114M VMD OF I camp 11-4 Or 5of <br />=OVAT BUSINESS INDUSM <br />I P-12 mm <br />OU e fe q!zj Domestic <br />It fj4'0A -MANE FMT MaootE LAST tr. LAST <br />Jobn Dickman Anna Bosselman <br />1WOAVAXT. NAME- &f$dAQADO1IESS (STREET OAFtFD. NCL. CM OR TOWN. STATE. <br />62821 <br />Cvw f2t, or W&) ""LIPMOvy"dow0awmal A <br />1 J. Shipman-Hasband-R.R.1 Box 230-GrEaAA a an( <br />Albert <br />20a tA1sEMtr+ CArAaMaAIYIMaraL <br />900. OAT15 <br />20-1 CEMETERY OR CROIATCfff , NAM <br />LOCATION cay on TOWN STATE <br />Burial <br />May 25, 1989 <br />Norwegian Cemetery <br />worms, Nebraska <br />NO. <br />2Z FUNERAL NOME -ki"AWAIMFIESS jST rA %.ra. NO. CffV DRYOVOL STATE ZIP) <br />Apfel-Butler-geddes 1123 W. 2nd, Grand island, NE.6880 <br />ONLY ONE CAUSE PER LINE OR (AL M AND MJ I <br />C-k <br />DUE To. Okp A CONSEOUW-f-w- <br />DUE 1O,0"A30WWnWJVWX OF. #j <br />OTN fel 34NOC Mi tZONDMONS • FZ-0-0 C9*00V W ONO 61A nue 1~ <br />PART a <br />PART 0 OF FEMUE. WAS YMERE A <br />PREGWNCY IN THE PAST 3 MONTHS? <br />24. AUTCPSv <br />w1troa"10) <br />ZS WAS CASE MIFEWD TO MEDICAL <br />FXAMREPIORCM41" <br />* <br />p <br />ti - <br />[Id <br />150* TIM or Aw <br />No <br />fa ACC4D ENT <br />2ft DATE OF SLIUM FM—AAW. YI) 26C HOUR OF [hit; <br />W-DF"U 1: <br />260 DESCftw140wIwURYOW F-f;CD <br />On PE <br />I 71E '��* <br />Zlvwfow- <br />2" LIVI.Ay <br />2% LOCATION STREET OR 0 FA) NO cav cp TOWN STAYS <br />j. e, <br />ISOICAY TO or NO 00014%t ft 150sew <br />26a DATE SIGNEO fhb. Ni 1114 12% <br />TIME OF DEATH <br />17a OA 5FG1KC IW6 rwl f1ri <br />Ve TONE OF DEATH <br />2k PRONOUNCED DEAD (Alb. 111K 1• <br />W- iA�IAOUWCEO DEAD <br />p <br />T M <br />ow <br />."Morewrecal <br />1110 Oft. dA* rd owe " aw 10 ra c&i•sj *Md <br />100 <br />iS <br />25a 00 T4 XKTAIDUTS TO THE DEATH? —13ft HAS CRUM OFITLSSUE DONATION KEN CONSIOMW <br />WD WASCONSENT GRANTED7 <br />a YES DAO a UNKNOWN a YES goo <br />0 VIES RNO <br />OF MTV—" MlItSICAM CORONER S PMYSICANOR COUNTY ATIORNEY1 fT9*GfRf4 <br />W. J. landis- M.D. 2444 Faidley. Grand Island NE. 68803 <br />3ft FIEGIbIft-A <br />AAAAW.J. e'Mna <br />3A OAtE FILED BY REG157PAR "0 Oh yr) <br />MAY 3 01989 <br />11 U5 <br />I <br />