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<br />WHEN TM COPY CARDS TIE RAISED SEAL OF THE NEBRASKA HEALTH AND H�#SERWCES
<br />SYSTEM IT CERT/FES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL ��QIYf![E�WITH �
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST_19�3N�WH/Cy�S q
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />- Y- �
<br />A MW STATE RE GC/OSSOTLINC� NEB0 � HEALTH AND FI5AR kWjCESTPME �tRs =
<br />9 �
<br />200109253 - C41
<br />STATE OF NEBRASKA - WIAMVENT Of HEALTH # It) O
<br />CERTIFICATE OF DEATH --
<br />iCEDENT -NAME f:RST MIDDLE LAST t SEA J DATE OF
<br />DEA'H Mtv.Pt pry Y..rl �,
<br />Josephine Leocadia STA
<br />rr AND Female
<br />TE os BnTN pn,r.r U A, nE n. tov+v Sa ADE -taw er- H -
<br />IYMI Se MDS OArS x .novas MINE E
<br />Grand Island, Nebraska
<br />,c1AL sECAwry TEIIIEBER Sa PLACE OF DEATI•. - -J-9
<br />HO SPIT I 0 d ER QM Otr DOA
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<br />aw nUlMrl k CITY. TOWN OR LOCATION OF DEATH COUNTY
<br />ea Ns10E cm L.AYrs M cOVNTV � DEATH
<br />IsP.c*r Y.A a Ncl 71
<br />FRANCIS MEDICAL CENTERI GRAND LAND NE Y
<br />ESOBECE •STATE tb COUNTY fc CRY. TOWN OR LOCATION VC STREET AND NUMBER Fla- H
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<br />Nebraska ALL
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<br />• M`. TEItr. EIII:IL AtttrritfA Ind,^. t t ANCESTRY N q .TINA^. ME„CM, tiAtmw OK I 4'.. RRIEp,NEYER MARRIED, 1,7 NAME OF SPOUSE 6ir r+r ty Y E G -�'
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<br />Salvador Chavez 122 E.
<br />OR CATEMATORY . NAME
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<br />Januar
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<br />Westlawn Memorial Park
<br />120E LOCAi,ON
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<br />WHEN TM COPY CARDS TIE RAISED SEAL OF THE NEBRASKA HEALTH AND H�#SERWCES
<br />SYSTEM IT CERT/FES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL ��QIYf![E�WITH �
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST_19�3N�WH/Cy�S q
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />- Y- �
<br />A MW STATE RE GC/OSSOTLINC� NEB0 � HEALTH AND FI5AR kWjCESTPME �tRs =
<br />9 �
<br />200109253 - C41
<br />STATE OF NEBRASKA - WIAMVENT Of HEALTH # It) O
<br />CERTIFICATE OF DEATH --
<br />iCEDENT -NAME f:RST MIDDLE LAST t SEA J DATE OF
<br />DEA'H Mtv.Pt pry Y..rl �,
<br />Josephine Leocadia STA
<br />rr AND Female
<br />TE os BnTN pn,r.r U A, nE n. tov+v Sa ADE -taw er- H -
<br />IYMI Se MDS OArS x .novas MINE E
<br />Grand Island, Nebraska
<br />,c1AL sECAwry TEIIIEBER Sa PLACE OF DEATI•. - -J-9
<br />HO SPIT I 0 d ER QM Otr DOA
<br />OTIF,q. G Nvanq clan. u RAE10A/,t. O o,n.. tsP.c�yr _
<br />aw nUlMrl k CITY. TOWN OR LOCATION OF DEATH COUNTY
<br />ea Ns10E cm L.AYrs M cOVNTV � DEATH
<br />IsP.c*r Y.A a Ncl 71
<br />FRANCIS MEDICAL CENTERI GRAND LAND NE Y
<br />ESOBECE •STATE tb COUNTY fc CRY. TOWN OR LOCATION VC STREET AND NUMBER Fla- H
<br />,W
<br />AArq Iro Coup
<br />t ;go INSIDE t•itr , w.Tg
<br />Nebraska ALL
<br />NM
<br />• M`. TEItr. EIII:IL AtttrritfA Ind,^. t t ANCESTRY N q .TINA^. ME„CM, tiAtmw OK I 4'.. RRIEp,NEYER MARRIED, 1,7 NAME OF SPOUSE 6ir r+r ty Y E G -�'
<br />WIDLoWED. DIVORCED ISp.Clyl
<br />Mexican Mexican ��
<br />m,AL ocul.Anllfl loa. afl d nar mIM d..g AIEr ,.. XfW of Ch av
<br />d��1Et tTtA�iwa,AlE
<br />_Homemake
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<br />slFSwESS INDUSTRY
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<br />Ear a s.ta,..,, c ,,,
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<br />VYJ1 )
<br />A -NAME EAST
<br />MIOOIE
<br />LAST t 7 MOTHER - MAIDEN NAME
<br />FIgST
<br />--
<br />-WlE
<br />7(�y
<br />//��
<br />Isabel NMN
<br />VMS DECEASED EVER
<br />Lo ez
<br />Abundia
<br />NMN
<br />M0. LAST
<br />Palomeiz
<br />7
<br />IYN n4 a,Frtl
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<br />tf f1fORMANT -NAME - LIAKMKi ADDRESS
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<br />24 AUTOPSY P
<br />NO
<br />! EIEEAL CrMtI,M
<br />Oawfa,
<br />""`
<br />IbntaiE4 200. RATE
<br />V,A `/ S
<br />20c. CEMETERY
<br />Salvador Chavez 122 E.
<br />OR CATEMATORY . NAME
<br />Bismark,
<br />68801
<br />Grand Island, Ne.
<br />Burial
<br />Januar
<br />9 1990
<br />Westlawn Memorial Park
<br />120E LOCAi,ON
<br />Grand
<br />qn L`R :OWN STATE
<br />-•�
<br />� f
<br />ENEMA" - TIIIIE 1
<br />ND.
<br />2Z FUNERAL NOME -NAME ANp ADDRESS
<br />Island Nebraska
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<br />aEI.i.A� a„a AM dtEE,
<br />PART 071,. 13,0 CONDITIONS - C0mI1Aa,A CWWV"tq b aw',a bE no rdEya PART EI IF FEMALE. WAS THERE A 2
<br />Pu. i•j . _
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<br />INJILOW AT 269 .? YMaIWI dEp OA10%,LT JSPNd1j•wN m� �q IOCATIUN STREET OR RFD NO f
<br />f,TV DRTOWN STATE
<br />279. DATE Of DEATH /At. DEy. n.l 2
<br />23A DATE SIGNED IW
<br />s TI UTA,r ! a
<br />t7f. D(1TE SGNED wP. �' X440 nt. TIME (IF DEATH 2k PRONOLINCEo 5 ,ft I.. M
<br />` \1 Nle PpOND LACED OF AO Karl
<br />L.�rt U" rY I i��
<br />2'M TO" 00=11 ry
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<br />a& DID TOEACOD um COWN&M TO A AM HAS ORLN MOT +
<br />OR TISSUE DONATION BEEN CONSIOERED+ 700 WAS CONSENT GRANTED•
<br />O YES ONO INNfNpyN O YES
<br />YES {yNn
<br />M. NAAI@ AND ADDRE36 OF CEMiIER (PHYSIC^ CORONERS PHYSCAh OR COUNTY - /� _
<br />ATTORNErI !IMP,W
<br />Dr. Wendell Burris M.D., St. Francis Medical
<br />Center. Grand Island, Ne._68803 '
<br />i l74 DAfE FILED Br nEC.t$T..AA L. JN... ,
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