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<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 />6/8/2020
<br />LINCOLN, NEBRASKA
<br />202004372
<br />J44.a.fi 81tAka-ree.
<br />Sarah Bohneakaap
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALI,TM
<br />AND HUMAN SERVICES,
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH (\6 20
<br />............l.Zi13�1Y;'1h((((( 5s!Ae�
<br />i0i �y 1
<br />-)p,) y1111�S�•
<br />tkt�e/rs
<br />PP DECEDENT-4NAMI FIRST MIDDLE IA$T
<br />i Mary Ann Morris
<br />SEX
<br />2 Female
<br />DATE OF DEATH (Mo., Day, Yr.)
<br />3 December 22, 1985
<br />RACE -(..g.. White, Black, Marken
<br />Indian. *H.)1122010
<br />itt '
<br />ORIOIN/DESCENT(e.g.,Italian, Mawkan,
<br />Genaan. •N.) (Specify) i.
<br />a. Arne ican
<br />AGE -lass lI bd.v
<br />(Yrs.)
<br />6a. 54
<br />UNDER 1 YEARI UNDER 1 DAY
<br />DATE OfIIRTN(M..,Day, Yr.)
<br />',Haut. 1, 1931
<br />MOS. ; DAYS
<br />ab.
<br />HOURMINS.
<br />S
<br />6c. !
<br />ITV AND Af 11RTN (If not in U.S.A., CITIZEN OF WHAT COUNTRY
<br />awn, combo
<br />a Altantic. Ion if ,. U.S.A.
<br />MARRIED, NEVER MARRIED, NAME OF SPOUSE (II wife, Kira RFa)den nem*/
<br />WIDOWED, DIVORCED (Specify)
<br />to. Married It1, Lavern Morris
<br />SOCIAL SECURITY NUMBER
<br />)R. 48.2-30-1142
<br />USUAL O,w
<br />CCUPATION (Give kind °(work done during est
<br />even if refired)
<br />ofworkiIIa Waitress
<br />13.. Waitress 1/3.
<br />RIND OF BUSINESS OR INDUSTRY
<br />17b. ; Tavern G40
<br />COUNTY OF DEATH
<br />1.a. Sherman
<br />CITY, TOWNORLOCATIONOPDEATH
<br />116. Loup City, Ne.
<br />INSIDE CITY LIMITS
<br />(Specs Ys •r NO
<br />u.. Yes
<br />HOSPITAL OR OTHER iNSTETUTION- Nam. ()Fnee ineither,
<br />Rive street end ember)
<br />ud. Sacred Heart Hospital
<br />IrNOSP.ORINST. MOW. DOA.'
<br />Ovlp.N.nt(Ewer. Rs.. 1wp.pool lipwily)
<br />14.. Inpatient
<br />RESIDENCE -STATE COUNTY
<br />7��`it
<br />ATl1 a $iCaPlRSldb. Hall
<br />CITY, TOWN OR LOCATION
<br />,T
<br />11c. Grand,Island
<br />STREET AND NUMBER
<br />W. 4th
<br />'5.1.16E 15ST
<br />INSIDE car UMITS
<br />(Specify Yes or N.)
<br />IS*. Yes
<br />� MIDDIE
<br />16. 1 :onard -- Gaines
<br />tt_iyulO
<br />17.
<br />MIDDLE LAST
<br />Dorothy' -- Burns
<br />WAS DECIASF EVER 114 U.S. ARMED FORCES?
<br />tr... we. to wni)I P Ns. giro .w and dere. 01 senior)
<br />ES. No
<br />INFORMANT -NAME -RELATIONSHIP -MAILING ADDRESS (STREET OE 1.1.0. NO., CITY 01 TOWN. STATE. IM)
<br />1,Lavern Morris Husband 1615 W. 4th Grand Island, Ne..6813J
<br />I,
<br />OURIAL, Cr•nro.i.n, Removal
<br />20. Bu ia].
<br />DATE
<br />Dec. 26, 1985
<br />CEMETERY OR CREMATORY- NAME
<br />m. Westlawn Memorial Park
<br />LOCATION CITY OR TOWN STATE
<br />2Dd. Grand Island, NE.
<br />EMBALMS NATURE 1
<br />I.
<br />L NO. ,.11 7
<br />,f Ar`J
<br />FUNERAL HOME -NAME AND ADDRESS (STREET OR 1.1.0. NO.. CITY OR TOWN. STATE. SIP)
<br />22A.fel-But - - r -Geddes 1123 W. 2nd Grand Island . Ne .68801
<br />23. .
<br />(Me
<br />D.y -'f
<br />�4...1.1-84-
<br />1.1
<br />G
<br />/X
<br />NED (Me. • ey, Yr.)
<br />241).
<br />TIa.
<br />N • UR •` DEATH
<br />216. M
<br />r
<br />DATE STONED (M.., Day, Yr.)
<br />L
<br />23b. l a, ..I.�p _ % S
<br />HOUR OF DEATH
<br />23e. ' ` 3S A A. M
<br />_
<br />5.,
<br />u; z
<br />PRONOUNCED DEAD
<br />(Me.,Doy,Yr.)
<br />24c.
<br />PRONOUNCED DEAD (Neer)
<br />244. M
<br />2 -it
<br />Ike boss M ave (n.deds., death eay.nd Mn Mna, dare end place and duo ,. IM
<br />004.
<br />-:13
<br />On the bads ori w.eeinnIww .wd(er Iw.o.MgaMon.
<br />As Mow. deb sod dve re No ce.W,).ssrsd.
<br />Iw ow opinion de.* .earsed w
<br />e
<br />comb) II•
<br />*ail now 1.
<br />%INoa.nwo i I •
<br />.!I
<br />sod plow
<br />24.. 04...... end Ade)lis
<br />NAL
<br />A re AIHNINSS CI, CF°TINE! IPNYSICIAN_ EECta0NE!'S PHYSICIAN 0! GOUNTY ATTORNEY)
<br />(Tma or PrinH
<br />im.1fitoDTlrurYV. Anantachai 130 N. 69 St. Louplity. Nebraska 68853
<br />DATE RECEIVED SY REOISTRAI M•., Day. Y.J.
<br />7Aie tE,gwraw.,►
<br />27, IMMEDIATE CAUSE
<br />(ENTER
<br />N'RT
<br />4.)
<br />DUE TO, OR AS:A CONSEQUENCE OF.
<br />414
<br />DUI TO, OR AS °A CONSEQUENCE OFs
<br />1' ONE CAUSE PER UNE 701(0). (b). AND (c))
<br />CARc(KbNk • L(MIC ?V(rlf MAW 141
<br />(c)
<br />FART meta SIGNIPKANT CONDITIOMS-CwwsiiMew, contributing On death bro... misted
<br />11 CpNtrtriVe A.A.I.
<br />l.Cl ibINt. autos*. HOMICIDE. UNOET..
<br />O! 11E1420I0 ITIVESAOATION. (Speak,)
<br />30a.
<br />(T)HLQA
<br />26b.
<br />MC,*A t1*- I'C
<br />PACT 1!. IF PEONALIE WAS THERE A
<br />PREGNANCY IN THE PAST 3MONTHS?
<br />YIN 0 No 1.
<br />DEC 3 O 1905
<br />1 IwMwd buleeeM errd owl Arlt
<br />rfuirgt
<br />AUTOPSY
<br />(Spad(y Ye. w Na)
<br />211.
<br />Safuwl h. wiat woof sod deed
<br />r
<br />•
<br />WAS GSE lel 030 MIDICAL
<br />ERAINNIN OR C' OROPI
<br />ISpWf, Yw ., Ne)
<br />2,. Alb
<br />DATE OF INJURY (Ma.. D•,. Ys.)
<br />30b.
<br />HOUR OF INIURi
<br />30.. M
<br />OESCbet NOW NOM OCCUEEED
<br />30d.
<br />RUURY AT WORT
<br />Sp.dIy Totter FJei
<br />SOI.
<br />MACE OF NAM- At bona. lank and. I.Mr7.
<br />rake ►vildiwg, sic (Somas)
<br />304.
<br />LOCATION
<br />STREET 01 1.1.0. No.
<br />CHT :QSTOWN STATE
<br />305.
<br />OJ
<br />CO
<br />
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