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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEA,�LYAND•14 SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBfj45 AQEIPARNOF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOft V L'fIFCORJJ,
<br />U�
<br />EY `.COOPER ' . rn• rl
<br />;ASSIST T:STATE EG,I5T -Y
<br />ART ttfENT`OF44 1HANp•'
<br />/1XINaSERVICES : ;C
<br />!� Q•:c
<br />,'• ASS •
<br />Q ; R
<br />DATE OF ISSUANCE
<br />05/20/2014
<br />LINCOLN, NEBRASKA
<br />202103321
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES V
<br />CERTIFICATE OF OWN,. DICIIDINT' NAME (Fkit. OMAN, Lot, sumo ' 3. DATS o. DEATH (I,..000.1
<br />Robert Gordon 'Everson December21, 2013
<br />7. sin
<br />Mals
<br />4.CITY NO$TATEORTRUNTORY,oRMINN Col1 TRYOFSIR'm
<br />Grand Island, Nebraska
<br />AOEdW EYEIduy
<br />O
<br />74
<br />M.WOW 1YEAR
<br />2.. UNC 1 DAY
<br />MOS,
<br />DAYS
<br />N00RI
<br />MNL.
<br />0. *Amor awns 0.0..77.7,
<br />October 27, 1939
<br />7.SOMAL se URRYNIIMIat
<br />505:44-3395
<br />M. MouT .NAME Sr not boltoSoe ylvs.tws wrRembed
<br />Saint Francis Medical Center'
<br />a► PLACI OF DEATH
<br />'124111M1j II *WOW
<br />DOAINUOMMIJKS
<br />Q Dawdler* Now
<br />O
<br />ab. CRY OR TOWN OF CEATH ( n► C.a.)
<br />Grand Island 88803
<br />ad COUNTY OP. DEATH
<br />Hall
<br />s► REWNiCIATAT!'
<br />Nebraska
<br />IM. cowry
<br />Hall
<br />DA CITY OR TOMN
<br />Chapman
<br />St STUNT PMD NAN =
<br />122181h Road
<br />N. APT. NO. -.
<br />M ZIP COON
<br />88827
<br />en. ORMECRY .MINTS -.
<br />0I» 111N•
<br />We. MARITAL STATUS AT'OW OFDMARI Melentedt]N.vs Mtn NA. :MOROPMOUSE IPMrf.IMO* Low. SWAN //INA oNs mddam Arm
<br />j .M.I,I.d.tut ..P.1.I.d' [] Whhwwd' [] DNsmw0 m.o.
<br />Judy Ann Stoltenberg
<br />11. PATHUR7•NAME (MM. QOM, Man Everson
<br />S ollba
<br />12IOTNINIs3NAME.(19rM,' Aaddld YOW.nM.ened
<br />Margaret Amend
<br />13. RYER II UA. ARMED FORCES? OM A.M. M wrvlp It Ye .
<br />NN Na er thIL) No
<br />14e.MIFORMANT4MYI
<br />Judy Ann' Everson,
<br />15. .ATIDNNMP TO DetlEDsR
<br />Spouse
<br />12 METHOD OF O1POgnON
<br />Dowd*a Mem
<br />®comm.. Onwsoined
<br />Onr»w Ocumleoldrd
<br />1e► NIIALMEJ41 ONATURE
<br />Not Embalmed
<br />142 LOOMS N0.
<br />December 23, 2043
<br />1sd
<br />colengtY, CIIfMATQRY OR 017AR LOCATION
<br />Centra Nebraska Cremation SeMoes
<br />17.. FUNERAL N011E NAME AND MAL110 ADOREI! iEM..a ONArTani, NIM.)
<br />AEI Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />88801
<br />CAUSE OF DEATH (See Instructions a exbrmilee)
<br />+....R?c.r,.. 4R1.«.q r.:mmot...r..,.r r m•!01.= 4111 » ..1w:
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<br />e.IMO a DUE TTT.ORAdACONNOIIBiCEOF: .
<br />!M.r*.UNONILYINOCAYIt el
<br />(A....e or eddy ohs k40451
<br />the evade 1.argnsM d..11a
<br />LAST _.
<br />o...11.4.aW 'T r0r/IiS� I.
<br />ci4 Vs.
<br />1 .
<br />odds 1 doom
<br />1L PART LMOT s1011R'MTOONmn Nacoodlbn.c.5.tl o Mae doelh bet not nestillnd Milts widwhylagmar OmlPART L
<br />1L- WAS NNOQAI. toserNM,
<br />OROOROINNO01ITA01W7
<br />Q yds 0 so
<br />;'. 20. IF FINALS:
<br />O Net pregnant Wigan Pw ywr
<br />O losemit.tNMI stNAM
<br />❑ NOe w.MIwi flat pommel catkin 42 dem o/ death . .
<br />D Not moment, but proptant 43 days W1 mowWo . death
<br />O Ssish mW11.s.wtMOMWepestyear
<br />'�20.. IM1AA'NMER OP MEATH
<br />la Madam 0 ,,.
<br />❑ au.wa 0 Cera not Mt
<br />VW. IR TRANSPORTATION INJURY
<br />DrMenatpeRlor
<br />DD P.w«w.r
<br />0 PooMon'
<br />OoelatIdeelM
<br />21L RM11ANJUT0P PEIMORMUD?'
<br />Dyes ' Ylao
<br />210. WERE AUTOPSY .PNDNOssorna s
<br />TO CONKETa:CANINO, °NIRN?....
<br />CI 'a* V 14
<br />22 . DATE OP INJURY Md. Day, W.)
<br />December 20, 2013
<br />Mb. TINS OF INJURY.
<br />2000 m
<br />222. PLACE OF INJURY.A1IIMMO.farm, alma. toasty, 'Moe tablas, Gamow:a.11DIM .old (spry)
<br />Engleman Elementary School
<br />WM.'. INJURY AT WORK?'.
<br />®YES Q*o
<br />22o. MICR= WPM INJURY OCCURRED
<br />Re haus an. unwitnessed: fall and: was found; down
<br />221. LOCATION OF INJURY • ow, A QMe'R. A►T.110.
<br />1812 Mansfield Rd.
<br />23.. DATE OF CMATTI (M0. D.N. Yr.)
<br />Dere/Saher .2/ , .2 o/3
<br />Grand Island..
<br />42b. DATA MONO (Ms., Do. Yr4 23e. TINE OF DEATH
<br />davoaser .23 . 013 / / go s
<br />234. To Oho best sl my ash a.pw ed Mid Med dab Sid pl.m
<br />and duo to rho hidnalw�o and TIM
<br />23: MID T0IA000 Wt CONTRINUTe TO TH[ DEATH?
<br />Ares 11 NO Ortio. ss.v CImoms
<br />.INTATE.,..,..
<br />Nebraska
<br />24.. DATE INONSI) (Mo. Dir. yo
<br />24e. PRONOUNCED DEAD (Ms.. Ory, Yr.)
<br />21b«TINE OF ODOR
<br />68803
<br />Md. TIME PRONOUNCRD DNIAD
<br />1144. Oa Ihewait.«.oMetioelkda.15 rlatd l_•llmbr.rpbren:Matheommed
<br />at Re Ims,Mae and Mum and deed M odNAND MAMA(1Ip iffsi r TME)
<br />NA. HAS 0110ANOR' MMUS DONA/1014I!!N CONIMERID?
<br />QYd 11 No
<br />241bc WASCONkM ORANtt0?
<br />Not Appends S 9I..Ie No Qves laNO
<br />27.R McTm.ENoADOREssaaRnRet(Typ«Poro
<br />Sun IR Lae, M.D., 908 N. Howard Ave.',Grand Island, NE 68
<br />801
<br />Mb.:OATEPLIO SYRN ISTRARt a.10s1, Yrs ".
<br />nnFC 1112013
<br />
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