|
r
<br />LEGAL:
<br />X
<br />M
<br />c
<br />S D ' o o or
<br />M
<br />M ri- o o o p�
<br />o N Co -n o vT
<br />m o
<br />D M
<br />Z cxT F—
<br />C Z r -70
<br />r- n ►-+
<br />C
<br />W � o
<br />co a
<br />- u, Co
<br />CIO
<br />Lot 15, Block 5 Bogs and Hill's Addition to the City of Grand Island,
<br />Hall County, Nebraska.
<br />*IMN THIS COPYCARWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN-SERVICES
<br />SYSTEM, L?CERTiFIES TW BELOW TO BE A TR! jE COPY OF THE ORIG*1AL RECORD DArl-7LE_NO TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIG&�CTICA i9llYCH'IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _
<br />DATE OF ISSUANCE
<br />90001101 - 'cooly
<br />DEC 12000 ASSIS#A8Rh►srTl;!
<br />LINCOLN, NEBRASKA HEALTH AND HCMAAIBE S SYSTENT_
<br />STATE OF N BRASKA -DW ARDOW OF HEALTH AM HUMAN SE3tVX3i& FV"NM AND SU"ORT
<br />VITALSTAT{SM a 0 03550
<br />CMTMCATE OF DEATH
<br />T. • FIALE faR6T MaODLE LAST 2 SEx 2 DATE OF MAT" Aft"" OM, YAr1
<br />Helen Johnson Female March 17, 2000
<br />1 ,EhD STATE OF EANTME 01WOU. SA. l NARGIO F/
<br />Milligan,. Nebraska',
<br />sELxIRTn NuuEEtt
<br />508 -09-1198
<br />.N.q �Aa1FMMMq�M,MMM/1V�IME)
<br />St. Franc = Center: _
<br />e
<br />Grand Island
<br />E° MM ' QAYS x tEMIIEa -� July 21, 1908
<br />r PLACE OF DEATH - -
<br />tcEFETK ®..ww OTHER! ❑ low" mom
<br />0E� ❑❑
<br />tl ft 4CVAWVOF DEATH „;,.•
<br />Hall
<br />L1 RESVIENCE -STATE
<br />R COMNTY -....
<br />21M DATE 21c CEMETEIMONCNEHAIOAY NAME
<br />k CITY. TOM OR LOCATION
<br />N
<br />March 20, 2000 St.
<br />k INSIDE CRY LIMITS
<br />Nebraska
<br />rn
<br />S D ' o o or
<br />M
<br />M ri- o o o p�
<br />o N Co -n o vT
<br />m o
<br />D M
<br />Z cxT F—
<br />C Z r -70
<br />r- n ►-+
<br />C
<br />W � o
<br />co a
<br />- u, Co
<br />CIO
<br />Lot 15, Block 5 Bogs and Hill's Addition to the City of Grand Island,
<br />Hall County, Nebraska.
<br />*IMN THIS COPYCARWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN-SERVICES
<br />SYSTEM, L?CERTiFIES TW BELOW TO BE A TR! jE COPY OF THE ORIG*1AL RECORD DArl-7LE_NO TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIG&�CTICA i9llYCH'IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _
<br />DATE OF ISSUANCE
<br />90001101 - 'cooly
<br />DEC 12000 ASSIS#A8Rh►srTl;!
<br />LINCOLN, NEBRASKA HEALTH AND HCMAAIBE S SYSTENT_
<br />STATE OF N BRASKA -DW ARDOW OF HEALTH AM HUMAN SE3tVX3i& FV"NM AND SU"ORT
<br />VITALSTAT{SM a 0 03550
<br />CMTMCATE OF DEATH
<br />T. • FIALE faR6T MaODLE LAST 2 SEx 2 DATE OF MAT" Aft"" OM, YAr1
<br />Helen Johnson Female March 17, 2000
<br />1 ,EhD STATE OF EANTME 01WOU. SA. l NARGIO F/
<br />Milligan,. Nebraska',
<br />sELxIRTn NuuEEtt
<br />508 -09-1198
<br />.N.q �Aa1FMMMq�M,MMM/1V�IME)
<br />St. Franc = Center: _
<br />e
<br />Grand Island
<br />E° MM ' QAYS x tEMIIEa -� July 21, 1908
<br />r PLACE OF DEATH - -
<br />tcEFETK ®..ww OTHER! ❑ low" mom
<br />0E� ❑❑
<br />tl ft 4CVAWVOF DEATH „;,.•
<br />Hall
<br />L1 RESVIENCE -STATE
<br />R COMNTY -....
<br />21M DATE 21c CEMETEIMONCNEHAIOAY NAME
<br />k CITY. TOM OR LOCATION
<br />go STREETANDNLOAKA w4%-wVmCvMM1
<br />March 20, 2000 St.
<br />k INSIDE CRY LIMITS
<br />Nebraska
<br />Hall
<br />Gtr CHI TOWN STATE
<br />Grand Island
<br />1908 W. 11th Ave.
<br />68803
<br />Y" F1 No ❑
<br />b RACE - p&• MMIM ■EC► A.wIgl111or1.
<br />ANCISM00,
<br />. MANN MewtvL OW"A 411n
<br />t? ❑ HAIRED
<br />❑ w*OMIED
<br />d•AM Nyman 1w w
<br />sIRa•Lrq White
<br />ill.
<br />181011:11114
<br />DUE TO. (Z � Q7NSEO ONCE( OF
<br />"EVER NEVER
<br />MAIIIIIIIED
<br />R1 oTYORCED
<br />11300MEOPSINDIM
<br />tY Uwft O0CYIATEO'7EwI�II�pi/l�yyo/rMM 4rAwynIMME
<br />10
<br />t.I EtEq OFEUSK.SSOMEISTIM
<br />PART IN OPA/I EPA 11P11.mw PART IF IF FEMALE WAS THEREA
<br />P PiIEONANCY M TIME PAST =HS' MO HST
<br />- 5�+�
<br />t5 EC
<br />ATEON 1
<br />ro vifto
<br />" a Sm10rr IatQl
<br />CoYP 11 r 015-1
<br />"House EY aner
<br />Housekeeping
<br />K FATEEA -NAME :... mom
<br />WT
<br />t7
<br />NOME MDE
<br />MIADEN SURNAME
<br />Emil
<br />Kotas I
<br />2r 2 N ,rtY� ANAL 0.0%MY
<br />Barbara
<br />Simic _
<br />t5 WAS OECEARD EVER M us
<br />Y.. ❑ No
<br />I% ofONMANT • NAME
<br />--_.
<br />(YAraV 1 RTr GAG M 006 raNtwoola
<br />276 DATE OF DEATH AMP OM► wi
<br />Gene Cameron
<br />2B. DATE SIGNED IMP An V, I
<br />I1110 .YPV.IEMIT MAIPMERUM MIND yn 1 V 1RT. NI• yw lyww —1
<br />7091 W_ Id *h St_ . _rrand 7Aland. NF_ FiAA01
<br />�E - SMGNATIIIE /
<br />2T. METHODOFD PORTION
<br />21M DATE 21c CEMETEIMONCNEHAIOAY NAME
<br />® ww ❑ Ir11IF.r
<br />March 20, 2000 St.
<br />Ma 's Cemete _
<br />EPEE _ NAMV
<br />216 CEMETERY OR CREMATORY LOCATION
<br />Gtr CHI TOWN STATE
<br />Apfel- Butler - Geddes
<br />Wood River,
<br />Nebraska _
<br />m FUNERAL MOMS 1 ILI.O NO. CRY OR TOMM STATE Mil
<br />1123 West Second, Grand Island, Nebraska 68801 -5899
<br />II MEDIATE CAMSE ENTER ONLY ONCE CAUSE PER I ME FOR Ip IEL AND ax
<br />' Mrw.n olwl .ne a►+.
<br />PART 0rAwl ak �hEWt.l RJ. — J�1
<br />`
<br />/)M►rAI
<br />•
<br />DUE TO. (Z � Q7NSEO ONCE( OF
<br />M.wr wl.wn aMr awr11
<br />C �
<br />M
<br />_
<br />r • wlrr tI.A.PA w" .mt O.AP
<br />10
<br />PART IN OPA/I EPA 11P11.mw PART IF IF FEMALE WAS THEREA
<br />P PiIEONANCY M TIME PAST =HS' MO HST
<br />- 5�+�
<br />24 AUTOPSY
<br />25 WAS CASE REFERRED TO MEDICAL
<br />ExAERNER OR CORONFH
<br />!F V Ia5•i YM No
<br />CN_ y
<br />Yr No
<br />Yr No
<br />EFa
<br />:!. DATE OF FIRMLY Alb. DFY. 177 2Ee HoqA OF 261 DESCRIBE NOW IhUURY OCCURRED
<br />❑ A.pa n ❑ Lowsw.LMa
<br />M
<br />❑ swa, C] P..&
<br />Me HAIRY AT woR1
<br />2r 2 N ,rtY� ANAL 0.0%MY
<br />269 LOCATION STREET ORRFD
<br />NO CITVORTOWN STATE
<br />❑ Et,AIMIo. MMrgHO1
<br />Y.. ❑ No
<br />--_.
<br />276 DATE OF DEATH AMP OM► wi
<br />2B. DATE SIGNED IMP An V, I
<br />2Ba TOM OF DEATH
<br />)- 1_1 — (3C3W
<br />` .
<br />`
<br />27a�QI1TE Ap�p�ON VTJ
<br />27c 1114 OF DEAN A
<br />cla
<br />2k PRONOUNCED DEAD M. Dry. Y, l
<br />29O. PRON( UNCE U DEAD ift—,
<br />—
<br />;{
<br />a
<br />au
<br />27e To nP twM M PM awa rN ar EP wP
<br />—
<br />2M On Fr oPw d.unr+Pw+ rrl a +N.apPIVI. w rrry w+YO^ am nccvl.a r
<br />CiINM.MI.a
<br />''
<br />F1. wo. INN, and pwo IYIO Ar la M C4~%) saw
<br />I rMT
<br />rtl TN
<br />'M 00 TOMCCO
<br />USE CONTROUT 111'1 208 HAS ORGAN OR TISSUE DONATION BEEN
<br />CONSIDERED'
<br />Ja.M WAS CONSENT GRANTE D>
<br />YES NO ❑ UNKNOWN YES
<br />�IED
<br />YES
<br />NAME ANDADORESS OF CERTIF] EMI/HYSICIAKCORONERS PHYSICIAN OR COUNTY ATTORHEYI JHWWPrwN
<br />Kimberly A.;Mici(els M . 729 MY ftff Ave.,, Grand Island,
<br />NE. 68803,,.,,.
<br />, -
<br />22D OAT&
<br />.. ..
<br />if fA11-
<br />I
<br />
|