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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMEk`�`OF',,HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSIr6RY�F1DR ""
<br />VITAL RECORDS.
<br />+
<br />DATE OF ISSUANCE � �
<br />NOV ? 0 1987 O o Q 8 V STANLEY S G00'PEk, DjktC.TOR
<br />LINCOLN, NEBRASKA -BUREAU OF VITh,1,6%TIST'ICS
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATHK, q/0
<br />DECEDENT -NAME FIRST MIDDLE LAST
<br />SEX
<br />DATE OF DEATH (Mo., Day, Yr.)
<br />2
<br />12. Male
<br />October 29, 1987
<br />1.
<br />-An.
<br />..
<br />-La.t Birthday
<br />NDER 1 YEAR
<br />UNDER 1 DAY
<br />nnz
<br />)S. DAYS
<br />�6b,
<br />HOURS . MINS.
<br />n -
<br />German 0k.)(Specify) (Yrs.)
<br />American
<br />�
<br />o�
<br />e
<br />s
<br />,May
<br />M
<br />n
<br />MARRIED, NEVER MARRIED,
<br />�
<br />nome
<br />�
<br />F-ri.
<br />� M
<br />r; sly)
<br />Nebraska
<br />U.S.A.
<br />Married
<br />Hewitt
<br />rn ;,
<br />C.
<br />10.
<br />„Gladys
<br />SOCIAL SECURITY NUMBER
<br />USUAL OCCUPATION (Give kind of work done during most KIND
<br />OF BUSINESS OR INDUSTRY
<br />COUNTY OF DEATH
<br />Ca
<br />Bake Shop
<br />Douglas
<br />12.506 -09 -4667
<br />13b.
<br />T)
<br />Q)
<br />�l
<br />INSIDE CITY LIMITS
<br />1 HOSPITAL OR OTHER INSTITUTION -Name (if not in either, If
<br />MOSP. OR INST. I.ditot. DOA,
<br />Omaha
<br />1(
<br />give dr d an number) Outpetbnt(E-
<br />' ar�Cson Memorial Hospital
<br />f Ti
<br />11b.
<br />„c_
<br />„d.
<br />„e.Inpatient
<br />RESIDENCE -STATE
<br />COUNTY
<br />CITY, TOWN OR LOCATION
<br />STREET AND NUMBER
<br />INSIDE CITY LIMITS
<br />,sa, Nebraska 11%.
<br />Hall
<br />rn
<br />115. d 612 W. 16th
<br />r
<br />FATHER-NAM FATMER-NAME FIRST MIDDLE LAST
<br />MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />Peter - - -- Kolbo
<br />1 Alta - - -- Depuy
<br />v
<br />„
<br />r >
<br />INFORMANT- NAME - RELATIONSHIP - MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />(Y.., no, or unY) I (If Y•., gi.y wor and dates of trvk.)
<br />N
<br />is. No
<br />is.
<br />,g. Gladys Kolbo- Wife -612 W. 16th -Grand Island, NE.68801
<br />BURIAL, Cremation, Removal
<br />DATE
<br />CEMETERY OR CREMATORY -NAME
<br />LOCATION CITY OR TOWN STATE
<br />Burial
<br />Nov. 2, 1987
<br />Westlawn Memorial Park
<br />®
<br />,.
<br />20b.
<br />20c.
<br />Yod. y
<br />EMBB SIGNATURE 6 LICENSE NO.
<br />FUNERAL HOME -NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />Apfel- Butler- Geddes 1123 W. 2nd, Grand Island, NE.68801
<br />DATE Of DEATH (Me., Day, Yr.)
<br />DATE SIGNED (Mo. Day, Yr.) HOUR
<br />OF DEATH
<br />s
<br />47a. October 29, 1987
<br />Crl
<br />.�
<br />M
<br />y(
<br />�_
<br />n 0
<br />s� t_
<br />DATE SIGNED (Mo., Day, Yr.)
<br />HOUR OF DEATH
<br />N
<br />v,
<br />'•
<br />4,b, November 10, 1987
<br />23,. 17: 43 M
<br />�tZ (Mo,,
<br />'i
<br />Day, Yr.)
<br />2k. 24d.
<br />CIO
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMEk`�`OF',,HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSIr6RY�F1DR ""
<br />VITAL RECORDS.
<br />+
<br />DATE OF ISSUANCE � �
<br />NOV ? 0 1987 O o Q 8 V STANLEY S G00'PEk, DjktC.TOR
<br />LINCOLN, NEBRASKA -BUREAU OF VITh,1,6%TIST'ICS
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATHK, q/0
<br />DECEDENT -NAME FIRST MIDDLE LAST
<br />SEX
<br />DATE OF DEATH (Mo., Day, Yr.)
<br />Glenn Howard Kolbo
<br />12. Male
<br />October 29, 1987
<br />1.
<br />RACE- (0.g., White. Block, Am*r(can
<br />ORIGIN /OESCE NT (e.g., Italian, Mexican, AGE
<br />-La.t Birthday
<br />NDER 1 YEAR
<br />UNDER 1 DAY
<br />DATE OF BIRTH (Mo., Day, Yr.)
<br />)S. DAYS
<br />�6b,
<br />HOURS . MINS.
<br />India k,) Specify)
<br />W1
<br />German 0k.)(Specify) (Yrs.)
<br />American
<br />76
<br />16, 1911
<br />e
<br />s
<br />,May
<br />CITY AND STATE OF BIRTH (If not in U.S.A.,
<br />CITIZEN OF WHAT COUNTRY
<br />MARRIED, NEVER MARRIED,
<br />NAME OF SPOUSE Of if&, give maiden name)
<br />nome
<br />I
<br />WIDOWED, DIVORCED (Specify)
<br />r; sly)
<br />Nebraska
<br />U.S.A.
<br />Married
<br />Hewitt
<br />B. Lodi,
<br />g,
<br />10.
<br />„Gladys
<br />SOCIAL SECURITY NUMBER
<br />USUAL OCCUPATION (Give kind of work done during most KIND
<br />OF BUSINESS OR INDUSTRY
<br />COUNTY OF DEATH
<br />of..rorking life, even ifrelired) Jake's
<br />113a. Baker
<br />Bake Shop
<br />Douglas
<br />12.506 -09 -4667
<br />13b.
<br />Ira. $
<br />CITY, TOWN OR LOCATION OF DEATH
<br />INSIDE CITY LIMITS
<br />1 HOSPITAL OR OTHER INSTITUTION -Name (if not in either, If
<br />MOSP. OR INST. I.ditot. DOA,
<br />Omaha
<br />(Specify Ye. ar No)
<br />Yes
<br />give dr d an number) Outpetbnt(E-
<br />' ar�Cson Memorial Hospital
<br />Rm.. Inpali.nt (Sp.cify)
<br />11b.
<br />„c_
<br />„d.
<br />„e.Inpatient
<br />RESIDENCE -STATE
<br />COUNTY
<br />CITY, TOWN OR LOCATION
<br />STREET AND NUMBER
<br />INSIDE CITY LIMITS
<br />,sa, Nebraska 11%.
<br />Hall
<br />115c. Grand Island
<br />115. d 612 W. 16th
<br />(Spe y Yes or No)
<br />,se. es
<br />FATHER-NAM FATMER-NAME FIRST MIDDLE LAST
<br />MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />Peter - - -- Kolbo
<br />1 Alta - - -- Depuy
<br />16
<br />„
<br />WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />INFORMANT- NAME - RELATIONSHIP - MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />(Y.., no, or unY) I (If Y•., gi.y wor and dates of trvk.)
<br />N
<br />is. No
<br />is.
<br />,g. Gladys Kolbo- Wife -612 W. 16th -Grand Island, NE.68801
<br />BURIAL, Cremation, Removal
<br />DATE
<br />CEMETERY OR CREMATORY -NAME
<br />LOCATION CITY OR TOWN STATE
<br />Burial
<br />Nov. 2, 1987
<br />Westlawn Memorial Park
<br />Grand IS Nebraska
<br />,.
<br />20b.
<br />20c.
<br />Yod. y
<br />EMBB SIGNATURE 6 LICENSE NO.
<br />FUNERAL HOME -NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />Apfel- Butler- Geddes 1123 W. 2nd, Grand Island, NE.68801
<br />DATE Of DEATH (Me., Day, Yr.)
<br />DATE SIGNED (Mo. Day, Yr.) HOUR
<br />OF DEATH
<br />s
<br />47a. October 29, 1987
<br />iy t_
<br />M -
<br />41a. 446.
<br />M
<br />y(
<br />�_
<br />n 0
<br />s� t_
<br />DATE SIGNED (Mo., Day, Yr.)
<br />HOUR OF DEATH
<br />PRONOUNCED DEAD PRONOUNCED
<br />DEAD (Hour)
<br />'•
<br />4,b, November 10, 1987
<br />23,. 17: 43 M
<br />�tZ (Mo,,
<br />'i
<br />Day, Yr.)
<br />2k. 24d.
<br />Zk=
<br />ap0
<br />T. the bnr of my Yne +ledge, deer curved of rime, daft end plea• end die re tM
<br />ww•(d .rot.d. •
<br />On Me bad. el a ominatien ond(er i Ky Nen, in y ePW.. death «tuned ar
<br />th. time, date end pl «a and dve h the taut(.) doted.
<br />E i
<br />e
<br />L)
<br />r
<br />.�
<br />0
<br />OE
<br />v
<br />2]d. fsignotur. and rill.)
<br />240. (Signatunt and Title)
<br />NAME AND ADDRESS OF CERTIFIER (PHYSTCIAF4, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Vincent F. Miscia, M.D., F.A.C.P., F.A.C•C. 4242 Farnam Omaha, NE
<br />25.
<br />REGISTRAR
<br />n�
<br />�J
<br />DATE RECEIVED BY REGISTRAR (Mo., Day, Yr.)
<br />�
<br />J
<br />'
<br />260. f signolunl �
<br />26b. NOV 1
<br />Wal
<br />Z7. IMMEDIATE CAU5E (ENTER ONLY ONE USE P R LINE FOR (a), ), AND (0) b.t.•en en..t end d.ath
<br />PART ;
<br />I
<br />11
<br />DUE TO, OR AS A CONSEOUENC 14 OF: { Interval between -..t end death
<br />9
<br />lb) FK
<br />DUE TO, OR AS A CONSEQUENCE OF Inh vaI between sore and d.ad
<br />C (.l
<br />(tl
<br />PART HER SIGNIFICANT CONDITIONS - Condition. c nibvring ro eorh but no r.I.t•d
<br />PART III. IF fEMAIE. WAS THERE A AUTOPSY
<br />PREGNANCY IN THE PAST S MONTHS, (Sp.cify
<br />Y.. et Nel
<br />WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER
<br />II f -
<br />NO
<br />(sp «ify Y.. aq tp)
<br />129.
<br />`
<br />res 0 No ❑ 28.
<br />ACCIDENT, SUIC ,HOMICIDE, UNDET.,
<br />DATE OF INJURY (Me., Day, Yr.)
<br />HOUR Of INJURY DESCRIBE
<br />HOW INJURY OCCURRED
<br />W PENDING INVESTIGATION. (Sp•ctlyl
<br />70a.
<br />SOb.
<br />JOc. M 90d.
<br />INJURY AT WORM
<br />PLACE 1 P INJURY- At hem., farm, .tr..t, feoo y,
<br />LOCATION STREET OR R.F.D. He. CITY OR TOWN STATE
<br />(sp«iryV «.r Me)
<br />130f.
<br />eHI_ b•ildinp, •k. (Specify)
<br />40•.
<br />30g.
<br />Lot Eight (8), in Abrahamson's Subdivision Number 3, to the City
<br />of Grand Island, Hall County, Nebraska.
<br />0
<br />N
<br />CD .
<br />O
<br />CD
<br />F-A
<br />M�
<br />0
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<br />M
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<br />D1
<br />CIO)
<br />CA
<br />gl'
<br />CDl
<br />0
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