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20 01 1.1 <br />,.1 <br />WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH ANQ HUM SERVICES <br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE OCL RECORECOTIIFILLLIM774 <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTNCSS€CION, WHK�_ f S <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />SEP 1 2000 <br />LINCOLN, NEBRASKA <br />OPR <br />ASSISTANT STATEREGI TRAR iLf <br />HEALTH AND HIMIAlli`SERVICES SYSTEA <br />CER :.9 :. 501 <br />3 GATE OF OHY5NWWI1RL MAP NNW <br />December 22, 1999a ma a maw Ana Dap tWelf' <br />June 22,_°1925' <br />& *yr aub.86 *ovum► Ya.a.au....aray <br />2 SEX <br />Male <br />508F16,3282 <br />Sa ADE -tameless, <br />,y./ 74 <br />tT 4,101RMNSNLD0$00 00AT .;i <br />,G�['at� �' Imlagd'� � aehcaalca <br />Nebraska' <br />.40,00 <br />Ran <br />«.►e:..,. ;` <br />'unite <br />'JUICIER 1 VGA <br />!i. sea I OATS • <br />SA PtACEOP DEATH. <br />HOEPRAL: 111Pailigt <br />❑ ERN °MORA' <br />UNDER IDAY <br />Ss NOUNSMNa <br />Ed PS S CITY LATS <br />Yes ®Wo❑ <br />Sc CTY. toficoLocAnopi <br />Grand Island <br />I. **Y.WE mow ANntMOmp.% ad <br />American <br />❑ DDA <br />Ss . COUNTY OF DEATH <br />i2 MAIMWD <br />❑ <br />E <br />N <br />NAMED <br />Hall <br />taw akapa-e..— <br />..0w+�s.t <br />Na. SWEET AND NMlER ANYIAT2b ONSS <br />2525 Del Monte 68803 - <br />WIDOWED <br />OWONCED <br />17 NAME OF GROUSE '/ail /LP1.IRIIANW W <br />Embree Anne Rains <br />NOM oCCUg171DI..O.r.R VUS MaE...a <br />If 'Nary AM MAINMY <br />Muaic Educato5.4l aeEum Direct <br />NE PAWNER : NMS. .. <br />tN IOND OF MADNESS INDUSTRY <br />or Education/Museum <br />IS. EDUCATION ISa.M*N WelWiNt.a/IIM� <br />EleaawayNYS d1Y Wtl1. Off. 11 Am S -s <br />AIDDtE.. . LAST- <br />Austin Learned <br />1a was alatauth sea.r MsirIM>;a rdsTicar: <br />Iwr+aADDResr, <br />2525 Defy eiA <br />Apfel-Butler-Geddes <br />iT MOTHER <br />Embree; A. Learned <br />TSTTEETORRFD NO. CITY OR TAY& STATE ;DO '. <br />Grand Island, NE 68803 <br />FWST. <br />Grayce'- <br />ita ME/14000f DOPOSITION <br />®MW ❑R.MD.a <br />❑ Csa.oll ❑ Does <br />Sib MATE <br />71d CHAT CRY OR CREMATORY NAME <br />Dec. 27, 1999 Grand Island Cemetery <br />Ola CEiETERY OR CREMATORY LOCATION. CITY ORTON% STATE <br />as PUNERAL NOME ADDRESS (STREET OR RF. 0 NO.. CITY Ca TOWN. STATE. DRI <br />1123 West Second, Grand Island, NE 68801 <br />Grand Island, NE <br />MEDIATE CAUSE .. <br />(ENTER ONLY ONE CAUSE PER LNG FOR IMA AM AND (cl <br />as-. <br />.11 -carr-ii net <br />PUN <br />E <br />0 Sado Penang <br />❑+• <br />-Cmmmmear gaNIR OM 1Ndw nt .. <br />SW DATE OF NdURY Mt. ay.. WJ <br />Sic HOUR OF INJURY <br />PART ■ F FEMALE WAS THERE A <br />PREGNANCY N TIE PAST 3 MORRIS" <br />Pass 10 -SE We .ri <br />M <br />7a AUTT//' <br />Dry�ry.PSr <br />YY. rill. N'EL <br />WA DESCRIBE HOW NANRY OCCURRED <br />.. nneno a..naua and ..an <br />Ulava Cannon 51..1 MAO ONO, <br />..e.a. MW. WOW IWO Wan <br />„4• <br />7s CASE REFERRED Tom am <br />E1IAMNER CA CORONER' <br />T'" SI N. n <br />1M NJURY AT WOO[ <br />YIN El No El <br />TSI �( N - Al Aa/y, ba. NMl Navy <br />200 LOCATION <br />STREET OR RF.D NO <br />LTa DATE OF DEATH, •W, Dia <br />toas <br />YTa DATE SEINED AAP Lay, W, • ` 7Tc. TINE OF DEATH <br />apt T•OAewe wo W.HI •eota ulaSass dd/�a. <br />(aa.N•• aldTWA' IA <br />Mala <br />IS. DATE DOTED AA. MAP a 1, <br />as <br />Psoopyrdcao DEAD <br />Osa Int <br />Car OR IOU. <br />as 'Em EA 055tH <br />STATE <br />ISA PNONOINCED DEAD Pbw <br />W. On ii.Weed...A_M.En Anda tnYumennok.nog yYUg4064WilPeda <br />'M .a►. datand Rare Af M a M1an.WN Wad <br />iSNn.A•. dna Taal Sr <br />750 WAS CONSENT ~SD, <br />SEEN OONSIOEAED? .,. <br />70. U.S ORGAN ORTISWJE DCWATON SEE <br />❑ YES g1. NO <br />❑Ym <br />St NICE AND ADDRESS OF CERTIFIER • COMM,S PWYSIOIAI ORCONAITY ATTORNEY' (T NI aFYaf <br />Larry L. Hansen M.D.: • • W. Failed, Grand Island, NE 68803 <br />f, <br />72f REGISTRAR <br />Om DATE FLED BY REGSTRAR Ob. Dar W I <br />JAN 3 2000 <br />