|
WHEN THIS COPY CARRFES THE RAISED SEAL OF THE NEBRASKA HEALTH AND H~ SERVICES
<br />SYSTEIK R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL Rfr"WON —A" WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTCSSMt10k:.WH1CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />OCT 16 2000 �o AR
<br />A��IS.1'ANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA HEALTHAN&WOMANORVICES,SYSTOW
<br />200009302
<br />STATE OF NEi UFA- OEPAlCMWff OF HEALTH $ 6 3
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE Of DEATH��LI
<br />.,. DECEDENT -NAME .. - MI
<br />_..
<br />DATE Of H (M.., Day. Yr.)
<br />1. EARL KAY
<br />?MALE 13. JUNE 17; 1986
<br />RACE - levy.. WAi,s, BbckAmeritew
<br />pK 'MiDESCENT(e- p- ,Noliew,/•icon,
<br />AGE - LUtiwAde,
<br />UNOfR !YEAR
<br />UNDER 1 DAY
<br />DATE Of tIRT11(Me., Day. Yr.)
<br />MOS. DAYS
<br />�6c
<br />MOORS
<br />Indian, ekj
<br />rn
<br />n
<br />.. E
<br />s. AME{
<br />�, 73
<br />".
<br />>. 1.RCH 25 1913
<br />CITY AND STATE OF ILIUM 111 .0 in U.S.A. A8
<br />T
<br />Z (1
<br />NAME OF SPOUSE (Moils, vita maiden nam*)
<br />name te.wray)
<br />'NE
<br />19.
<br />WIDOWED, DIVORCED(Speti/hl
<br />lit.
<br />B. GRAND ISLAND
<br />u.S.A.
<br />CAROLINE SCHWIEGER
<br />SOCIAL SECURITY w-varR
<br />UAL OCCUPATION (Give kind of cork done daring mcst
<br />BUSINESS OR INDUSTRY
<br />COUNTY OF DEATH
<br />lKINDOF
<br />working life, even if retired).
<br />Ea.
<br />=
<br />fTT
<br />v
<br />RETIRED - FARMER tae.
<br />AGRICULI
<br />rdt,.
<br />CD
<br />p —i
<br />N
<br />•`m
<br />RESIDENCE- STATE.
<br />COUNTY `- :.
<br />CITY, TOWN OR LOCATION.... TREET AND NUMBER
<br />INSIDE CITY LIMITS
<br />IRT
<br />CCD
<br />tsa. NEBRASKA -
<br />,sb. -HALL" -
<br />,x. GRAND ISLAND sd. 2 .BOX 43A
<br />�s.Y
<br />PATHU-NAME FIRST MIDDLE LAST
<br />rn
<br />,, CHARLES KAY
<br />-<
<br />WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />Q .
<br />N
<br />.
<br />is. NO I
<br />isWIFE: "CAROLINE KAY. RT2 BOX 93A. GRAND ISLAND, NE 68801
<br />BURIAL, Cremation, Removal
<br />cl�
<br />N
<br />p 'n
<br />Zoo. BURIAL
<br />2obITITNE 20, 1986
<br />e.i
<br />god. GRAND ISLAND. NEBRASKA
<br />R- SIGNATURE i LICENSE M9.
<br />FUNERAL HOME -NAME AND ADDRESS (STREET OR R.► 0- NO.. CITY OR TOWN. STATE, ZIP)
<br />3
<br />CD
<br />_q
<br />�
<br />.....
<br />DATE OF OEATH (Me.. Day, r.);
<br />DATE SIGNED (Me. Day, Yr_) HOUR
<br />OF DEATH
<br />t 0
<br />c�
<br />240. 24b.
<br />u �
<br />O
<br />to
<br />p�
<br />HOUR OF DEATH
<br />PRONOUNCED DEAD PRONOUNCED
<br />DEAD (No.,)
<br />©
<br />rn
<br />V
<br />y" c�'
<br />(M... Day, 0.r.)
<br />.-�
<br />=y
<br />23b. June
<br />225. M M
<br />VIZ
<br />24. 24d.
<br />0
<br />To III. Ilea of my Ime"• go. d-wk .maned w Ilse riee, d.0.. —4 F4-. .d d.. ter"
<br />r
<br />s
<br />couse(s) slst.d.
<br />i
<br />Ci
<br />dl. N0., dar...d ►l.t...d dve 9. 1b. pave(.) O ftd.
<br />21 .1 Fipww. end riot.)
<br />u
<br />24s. (Sig -1— ..d T:ny
<br />Nza AND ADDRESS Of CERTIFIER IAN, G R'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />CD
<br />REGISTRAR
<br />IFATE REC IYED BY REGISSTRAR (Mo., Day, Yr.) "
<br />26o.(S' — #mvJB'
<br />26b. �Jr1Q2�`__ -
<br />1 A �" NNA ONLY ONE CAUSE ►ER LINE FOR (o), (b�). ANNDD (t)) - . I.w.. .w..w .w..I ..d d.els
<br />►YT C✓�.,.- P,.;.�..�/� / <<�„�vs,,If�Ls�,.� d..��� %- ,- t..— r....�,�
<br />wt
<br />OUR TO. 01 A3 A Co"MQ NmE oft + tnMv.l ►.I//w.e .wsl ..d McMI
<br />(bI
<br />DUE W. o,BpAS A CONSEQUENCE Of, F Iwa'wi ►.w..w wNn.wd b.w
<br />PART — e"ill.a. tew)rib.%.* N doe^ ►.t .m ,elsied
<br />►AIt ut M F E WAS iMlp A Aut
<br />ME6NANCT IN 1111 PAST S MONTMS1 (specioF Y"90"' I
<br />wAS CASE II ►IMD A1E t
<br />IRA+settR W CORONIR
<br />M -
<br />:.
<br />SM'II r , - NO)
<br />Y« Cl He 0
<br />ACCIDINT, I L IMtDI .. BAf! W INTUIT (Mw. D." Y..!
<br />HOVE p MYVRT OtSCfiIE
<br />llO+tt i►Ub'tY OCCIieiED
<br />OR ►INDING w4b" AttON. (110041
<br />13W
<br />CJ)
<br />N
<br />c
<br />10UM AT WON PLACII OF MOM • At . s..ct fe WO,
<br />STIIET UR R. ►.0. Me, CITY Oil TOWN STAII
<br />(110.900 Ym r A) cIR9s bok%m& eta (SPotMy1
<br />110CAT100
<br />POM 301. _
<br />G!1
<br />WHEN THIS COPY CARRFES THE RAISED SEAL OF THE NEBRASKA HEALTH AND H~ SERVICES
<br />SYSTEIK R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL Rfr"WON —A" WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTCSSMt10k:.WH1CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />OCT 16 2000 �o AR
<br />A��IS.1'ANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA HEALTHAN&WOMANORVICES,SYSTOW
<br />200009302
<br />STATE OF NEi UFA- OEPAlCMWff OF HEALTH $ 6 3
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE Of DEATH��LI
<br />.,. DECEDENT -NAME .. - MI
<br />_..
<br />DATE Of H (M.., Day. Yr.)
<br />1. EARL KAY
<br />?MALE 13. JUNE 17; 1986
<br />RACE - levy.. WAi,s, BbckAmeritew
<br />pK 'MiDESCENT(e- p- ,Noliew,/•icon,
<br />AGE - LUtiwAde,
<br />UNOfR !YEAR
<br />UNDER 1 DAY
<br />DATE Of tIRT11(Me., Day. Yr.)
<br />MOS. DAYS
<br />�6c
<br />MOORS
<br />Indian, ekj
<br />Getman. Nc.1 (S eci ) ��
<br />ia.
<br />(Y- -)
<br />.. E
<br />s. AME{
<br />�, 73
<br />".
<br />>. 1.RCH 25 1913
<br />CITY AND STATE OF ILIUM 111 .0 in U.S.A. A8
<br />CITIZEN OF WHAT COUNTRY
<br />MED, NEVER MA.PRIEO,
<br />NAME OF SPOUSE (Moils, vita maiden nam*)
<br />name te.wray)
<br />'NE
<br />19.
<br />WIDOWED, DIVORCED(Speti/hl
<br />lit.
<br />B. GRAND ISLAND
<br />u.S.A.
<br />CAROLINE SCHWIEGER
<br />SOCIAL SECURITY w-varR
<br />UAL OCCUPATION (Give kind of cork done daring mcst
<br />BUSINESS OR INDUSTRY
<br />COUNTY OF DEATH
<br />lKINDOF
<br />working life, even if retired).
<br />Ea.
<br />12. 5 - -
<br />RETIRED - FARMER tae.
<br />AGRICULI
<br />rdt,.
<br />CITY, TOWN OR LOCATION OF DEATH INSIDE CITY LIMITS HOSPITAL OR OTHER INSTITUTION - Nome (if not in eifbcr,
<br />ST, IwditeN OOA.
<br />(Sp.e' Na) give sash and nemb«)
<br />LINCOLN _
<br />1�7t
<br />1.1,. t.t. t dd.
<br />RESIDENCE- STATE.
<br />COUNTY `- :.
<br />CITY, TOWN OR LOCATION.... TREET AND NUMBER
<br />INSIDE CITY LIMITS
<br />IRT
<br />«NO )..
<br />tsa. NEBRASKA -
<br />,sb. -HALL" -
<br />,x. GRAND ISLAND sd. 2 .BOX 43A
<br />�s.Y
<br />PATHU-NAME FIRST MIDDLE LAST
<br />tst AktODI lA3T
<br />,, CHARLES KAY
<br />17 ANTONIE LILLIENTHAL
<br />WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />INFORMANT — NAME —RFLA r1ONSHIP— MAILING ADDRESS (STREET Of II -F D. NO.. CIV OI MJWN. STATt. ZIP)
<br />(T -. ne. - awl) (" v«. eiv —end do," .I v.n.t.1
<br />.
<br />is. NO I
<br />isWIFE: "CAROLINE KAY. RT2 BOX 93A. GRAND ISLAND, NE 68801
<br />BURIAL, Cremation, Removal
<br />DA
<br />CEMETERY OR CREMATORY -NAME
<br />LOCATION C11r OR TOWN STATE
<br />Zoo. BURIAL
<br />2obITITNE 20, 1986
<br />tot. WESTLAWN MEMORIAL PARK
<br />god. GRAND ISLAND. NEBRASKA
<br />R- SIGNATURE i LICENSE M9.
<br />FUNERAL HOME -NAME AND ADDRESS (STREET OR R.► 0- NO.. CITY OR TOWN. STATE, ZIP)
<br />3
<br />LIVINGSTON- SONDERMAN F.H., GRAND ISLAND, NE 68801
<br />: rIlllir
<br />22.
<br />DATE OF OEATH (Me.. Day, r.);
<br />DATE SIGNED (Me. Day, Yr_) HOUR
<br />OF DEATH
<br />22a. June 17 1986
<br />>z.
<br />aE
<br />240. 24b.
<br />M
<br />$X0
<br />s=p
<br />T ED (Ake., Day, Yr.)
<br />HOUR OF DEATH
<br />PRONOUNCED DEAD PRONOUNCED
<br />DEAD (No.,)
<br />(M... Day, 0.r.)
<br />23b. June
<br />225. M M
<br />VIZ
<br />24. 24d.
<br />- M
<br />To III. Ilea of my Ime"• go. d-wk .maned w Ilse riee, d.0.. —4 F4-. .d d.. ter"
<br />o. " b-i..f ...m ..l ....d).0. i—viecrien, ;I .l i.ion dw k «.a ..d M
<br />s
<br />v
<br />couse(s) slst.d.
<br />i
<br />Ci
<br />dl. N0., dar...d ►l.t...d dve 9. 1b. pave(.) O ftd.
<br />21 .1 Fipww. end riot.)
<br />u
<br />24s. (Sig -1— ..d T:ny
<br />Nza AND ADDRESS Of CERTIFIER IAN, G R'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Dr. Walt
<br />REGISTRAR
<br />IFATE REC IYED BY REGISSTRAR (Mo., Day, Yr.) "
<br />26o.(S' — #mvJB'
<br />26b. �Jr1Q2�`__ -
<br />1 A �" NNA ONLY ONE CAUSE ►ER LINE FOR (o), (b�). ANNDD (t)) - . I.w.. .w..w .w..I ..d d.els
<br />►YT C✓�.,.- P,.;.�..�/� / <<�„�vs,,If�Ls�,.� d..��� %- ,- t..— r....�,�
<br />wt
<br />OUR TO. 01 A3 A Co"MQ NmE oft + tnMv.l ►.I//w.e .wsl ..d McMI
<br />(bI
<br />DUE W. o,BpAS A CONSEQUENCE Of, F Iwa'wi ►.w..w wNn.wd b.w
<br />PART — e"ill.a. tew)rib.%.* N doe^ ►.t .m ,elsied
<br />►AIt ut M F E WAS iMlp A Aut
<br />ME6NANCT IN 1111 PAST S MONTMS1 (specioF Y"90"' I
<br />wAS CASE II ►IMD A1E t
<br />IRA+settR W CORONIR
<br />M -
<br />:.
<br />SM'II r , - NO)
<br />Y« Cl He 0
<br />ACCIDINT, I L IMtDI .. BAf! W INTUIT (Mw. D." Y..!
<br />HOVE p MYVRT OtSCfiIE
<br />llO+tt i►Ub'tY OCCIieiED
<br />OR ►INDING w4b" AttON. (110041
<br />13W
<br />200.
<br />M
<br />10UM AT WON PLACII OF MOM • At . s..ct fe WO,
<br />STIIET UR R. ►.0. Me, CITY Oil TOWN STAII
<br />(110.900 Ym r A) cIR9s bok%m& eta (SPotMy1
<br />110CAT100
<br />POM 301. _
<br />I�
<br />
|