Laserfiche WebLink
MEN THIS COPY CAMMS THE RAISED SEAL OF THE NEBRASKA HEALTH AND <br />SYSTEM, IT CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REQ <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTAW, <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE <br />MAY 2 52000 <br />LINCOLN, NEBRASKA ASSI$t'A; <br />HEALTH AND H44AN4 <br />TH`' .. <br />200111210 <br />STATE Cf /EaRAa[M G�A�l1�fl ORllAi.1H A1O 1R�111N S'F�VICES pOdATiLTi A?D St�IORT . <br />�ALSTAT <br />� 99 02190 <br />�W-OFDM� <br />PART OF FEMALE WAS THERE A <br />.a SEMI <br />1 OATS OF DEATH .6b." Dnv rAAy <br />to Ei <br />P ECl/ANCY N THE PAST J MpMHS' <br />9 1 <br />Alp FAIL � AAOIAISA wtwgl Y • LAOt G61AF1r UMM T MAR <br />UOIDER t DAY <br />t DATE OF 20TH ARn4 OA. Y.trt <br />Mll S► f6D6 <br />OAYi <br />:E• DATE OF NJUR Y /Mt. Dw: Wj <br />� <br />rn <br />N <br />1 1 <br />© <br />b RACE OF REAM <br />T <br />..;.p <br />fi <br />r •Irro. .. ... IwrwrrtAr.�rwwA+r!r!iui/ -.. <br />z <br />R <br />= <br />Ns" CITY Ums <br />66 CONTY OF DEATH <br />---a <br />ca <br />o <br />. : -=A E„ <br />S► COUNTY <br />m <br />> <br />trT <br />p <br />E. wv arts <br />Nebraska <br />rn <br />z <br />-� rn <br />N <br />CCD <br />•w%.IMrA FeA A1.�brltyrl. <br />tt. ANCE4STRV*s%0rLMw . un.0rwrlwcf <br />t2 (""� <br />!�'E"ER <br />pM100NE0 <br />to NA140i sE'OtMt A.A.MMM•ti�rY <br />Q°•a, American <br />UNVIED <br />oAloRCCO <br />V. Frendi <br />W USIWOODLO ION Ao•AMAF.wA 1wIMEy HON f t4D KNO OF BUSrLESS NDUSTRY <br />OLwAY7LALwwi10w0� <br />LIS EOUCATpN !9o.cA10 .NF <br />— <br />EAI'.80 ws6ea1, 013t Wep 11 Ae S, <br />t�{E_y <br />ow HMO <br />K FA .WM �T -- {rppL LAST WIND <br />i?th <br />ErIST WIDEN SUMAW <br />Richard A. Smith Sr. <br />Viola NMI Hammher <br />Ml'N U s NIMM FORCEST t11A NFORh~ . NA►E <br />ft'"mowa/- INV"va wwco"TO rww <br />No V. <br />Emnch <br />A. OR TISSUE DONATION BEEN <br />CONSIDERED' <br />T GRANTED, <br />❑ YES 1�1 NO p VpgwR <br />. <br />NO <br />❑ YES NO <br />I rui AYI1 AfYIRGee nc nm.em ..wc..•.... �.w..�.....,.�...... <br />rn <br />r- � <br />r <br />~ <br />Cn <br />Cn <br />7C <br />N <br />co <br />Cn <br />MEN THIS COPY CAMMS THE RAISED SEAL OF THE NEBRASKA HEALTH AND <br />SYSTEM, IT CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REQ <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTAW, <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE <br />MAY 2 52000 <br />LINCOLN, NEBRASKA ASSI$t'A; <br />HEALTH AND H44AN4 <br />TH`' .. <br />200111210 <br />STATE Cf /EaRAa[M G�A�l1�fl ORllAi.1H A1O 1R�111N S'F�VICES pOdATiLTi A?D St�IORT . <br />�ALSTAT <br />� 99 02190 <br />�W-OFDM� <br />]!1d CEMETERYORCAELMtORYLOCAT.ON Gtr QA Q10.M STATE <br />olliff nrl-Am- 14- VA-1 Kleine Funeral Home p�.,.r1 pDAnAO. F'hilli Kansas <br />r21 W. Noth F t., Grand I La d, Nebraska 68803 <br />111r, 7m nc�c K7KK1 <br />AAEDMTE CAU SE CAUSE PER lME fp1 I.1 0L AND KM Mwral pelr��n p•.t W porn <br />ANT �YL_/ <br />I �VilCdr.�ld1l � � <br />— ouc ra OR As JF.ONSEOUENCE of <br />to <br />DUE TO. OR AS A CONSEOUENCE OF Y.wrr oa1...n aw1.ro Oran <br />Ia <br />PART OTHER WUNWICANT O0ND1T1004S Cwar cW*OWVb M 0800 bA not Mr.p <br />PART OF FEMALE WAS THERE A <br />.a SEMI <br />1 OATS OF DEATH .6b." Dnv rAAy <br />to Ei <br />P ECl/ANCY N THE PAST J MpMHS' <br />9 1 <br />Alp FAIL � AAOIAISA wtwgl Y • LAOt G61AF1r UMM T MAR <br />UOIDER t DAY <br />t DATE OF 20TH ARn4 OA. Y.trt <br />Mll S► f6D6 <br />OAYi <br />:E• DATE OF NJUR Y /Mt. Dw: Wj <br />Se 1QtNS'. LAN E <br />PaYton. Ohio 80 1 <br />1 1 <br />foupwwNLRtBFJO <br />b RACE OF REAM <br />298-0 <br />..;.p <br />w..» on�l N1F617 Hp�F <br />, p ❑ <br />/J�Otytw~_. QEw'in <br />r •Irro. .. ... IwrwrrtAr.�rwwA+r!r!iui/ -.. <br />St• Francis Medical Center <br />Y« p Np p <br />p ODA p Orw Jbof*, <br />Ns" CITY Ums <br />66 CONTY OF DEATH <br />- Qmnd Island YIN ® N6 . ❑ <br />l7nJ•l <br />. : -=A E„ <br />S► COUNTY <br />ac C". 70" OR LOCATION <br />02 -09-99 <br />M STAEETANDPIU A" A�+1Sb0Aw <br />E. wv arts <br />Nebraska <br />Mall <br />(rand Island <br />EEC PRONOl1NCED DEAD qb: rrl <br />2508 West 5th St. 68803 <br />rr ® ❑ <br />•w%.IMrA FeA A1.�brltyrl. <br />tt. ANCE4STRV*s%0rLMw . un.0rwrlwcf <br />t2 (""� <br />!�'E"ER <br />pM100NE0 <br />to NA140i sE'OtMt A.A.MMM•ti�rY <br />Q°•a, American <br />UNVIED <br />oAloRCCO <br />V. Frendi <br />W USIWOODLO ION Ao•AMAF.wA 1wIMEy HON f t4D KNO OF BUSrLESS NDUSTRY <br />OLwAY7LALwwi10w0� <br />LIS EOUCATpN !9o.cA10 .NF <br />— <br />EAI'.80 ws6ea1, 013t Wep 11 Ae S, <br />t�{E_y <br />ow HMO <br />K FA .WM �T -- {rppL LAST WIND <br />i?th <br />ErIST WIDEN SUMAW <br />Richard A. Smith Sr. <br />Viola NMI Hammher <br />Ml'N U s NIMM FORCEST t11A NFORh~ . NA►E <br />ft'"mowa/- INV"va wwco"TO rww <br />No V. <br />Emnch <br />]!1d CEMETERYORCAELMtORYLOCAT.ON Gtr QA Q10.M STATE <br />olliff nrl-Am- 14- VA-1 Kleine Funeral Home p�.,.r1 pDAnAO. F'hilli Kansas <br />r21 W. Noth F t., Grand I La d, Nebraska 68803 <br />111r, 7m nc�c K7KK1 <br />AAEDMTE CAU SE CAUSE PER lME fp1 I.1 0L AND KM Mwral pelr��n p•.t W porn <br />ANT �YL_/ <br />I �VilCdr.�ld1l � � <br />— ouc ra OR As JF.ONSEOUENCE of <br />to <br />DUE TO. OR AS A CONSEOUENCE OF Y.wrr oa1...n aw1.ro Oran <br />Ia <br />PART OTHER WUNWICANT O0ND1T1004S Cwar cW*OWVb M 0800 bA not Mr.p <br />PART OF FEMALE WAS THERE A <br />AUTOPSY <br />ERRED TO MEMAL <br />P ECl/ANCY N THE PAST J MpMHS' <br />�WAS <br />ORONE RI <br />$A60A 1044 rw N0 <br />Y" Np <br />No El <br />Y <br />.ACOe.6 <br />:E• DATE OF NJUR Y /Mt. Dw: Wj <br />76c HOUR OF N.AtRY na DESCFNBE HOW HAIRY OCdMRED <br />❑ UF400 rrd <br />''1 <br />M <br />J %.do C Pa.* <br />766 NAAIY AT100011K <br />761 PLA['E Of M ILy 1p! ». bm Yr.oT MCWv <br />p6c. ntl16 SPM'M <br />269 LOCATION STREET OR R F D NO 01, OR TONM STATE <br />7 1L0..cb w•.Aw.pn <br />Y« p Np p <br />GATE OF DEATH OW qtr rrj <br />7sA DATE SiGMM Aft qw r11 <br />76D TIME OF DEATH <br />02 -09-99 <br />I + <br />M <br />. GATE SpNED Ab. Dar Yil <br />c TAE OF DEATH <br />EEC PRONOl1NCED DEAD qb: rrl <br />IW <br />76d PRONOl11CFD DEAD At—, <br />M <br />M <br />To ti 0.1101 mp 0r1oW04o. Mow pctu7p M h M1l Woo App 01st. AnF 6w b M <br />:M. On M tMn d r.anlYUOpn nd a nwloplLVi ^ nM 0pnpn O.oF. u0nr..0 r <br />3 <br />c•YOO % rr16 017- <br />6 <br />M Wft Cl N An0 010,."Oka b M ca vj wwld <br />rd Lem <br />� and TOM <br />A DID TOBACCO USE CON11TCC77 DEA <br />A. OR TISSUE DONATION BEEN <br />CONSIDERED' <br />T GRANTED, <br />❑ YES 1�1 NO p VpgwR <br />- ❑ 'Es <br />NO <br />❑ YES NO <br />I rui AYI1 AfYIRGee nc nm.em ..wc..•.... �.w..�.....,.�...... <br />IR��GA1� �A10/►'! �11b60r[ i��A .:`- a.Ir.�?ri1�•. °.r�e'er�Y� <br />o� <br />�1 Q <br />p;1 <br />C9 <br />S <br />v? <br />v <br />