|
$11IdIA2 Awl: E0441%,+„
<br />ti�A43i�(��,iRs4%/IIJ/1a �
<br />lllk/WiWdAAsxaz.Q��i'$1(iTT!?)a�teS.%i.�a,�59iT�dAAx �?�
<br />Sa h►+ri++
<br />STATE OF NEBRASKA wl ` ,� II
<br />19EEDIL+rns . , rrnm ' 4 '11V
<br />04EN,TH1S COPY CARRIES THE RAISED SEAL OF STATE Ole NE>SRASKA IT CERTIFIES THE DOCUMENT BELOW TO
<br />'BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH"THE NEHRASKA "•DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />ATE OFF ISSUANCE
<br />4/4/2025
<br />t;INCO N, N68RASKA
<br />DECEASED —NAME Slat/
<br />MAO sl ;;«,ate all�;ll
<br />10C.:,l s0'T,CjL1Rl.' . ,
<br />N W OI..1,
<br />CITY. TOWN, OR LOCATION OP DEATH
<br />STATE C P: $I>Rf t I a Fat N : 4 $ .•. NMNe
<br />CO.—','
<br />Nebraska
<br />SOCIAL SECURITY NUMBER
<br />It;:'.501'm 59
<br />AlS►Ofl+[CE; 57ATE
<br />)6L4CA
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRAS DEPAR A�1)1ENT
<br />u bF tEALTi1
<br />Burraof?dal; taliecst.
<br />CERTIFICATE CIF'DEATH j,..}J
<br />AGE —usw
<br />-10011 ! 1.i,
<br />Jean
<br />'I aar:
<br />110s j Gass
<br />ss
<br />I
<br />w
<br />srI C1I 1rN1
<br />5/4CI11 Ws 00 NO
<br />' No
<br />CITIZEN CM WHAT COUNTRY
<br />II. S. A.
<br />Ps
<br />sr
<br />76 08242
<br />1a14 4141 Nw.MS
<br />SEX DATE Of OEAih 1 •O-1N, lag. .140I
<br />'ema1e TJ1217 25, 1976
<br />DATE op I*ITH V TOWN
<br />V. COUNTY Of DEATH
<br />Mail21, 1941 „ Hall
<br />HOSPITAL OR OTHER INSTTUTION—NAME IN N01 w *owe 0N. 1101/ 41* 1.014!•.
<br />Higtaitay 2 : & ' 281 North of Grand Island "
<br />MMRIiD WRYER': ALARMED. 'SURVIVING SPOUSE 1N mot, owe -ae.N .-1N
<br />IwTDowcD e .1Nlf+YA ' „Alpert Moeller Jr.
<br />N 1N USUAL OCCUPATION 141.0 0 woo.
<br />1.0110.0 INS. MN N MSMO 1
<br />COUNTY�,,, -T
<br />iN Hall
<br />EATNER-.NAM( 011131
<br />IE• ; Willie
<br />rt..ell�q � sw.
<br />Housewi
<br />fe
<br />00.4 001111 N1a 0s, 01
<br />Pi
<br />CITY, TOWN, OR IOCAt'ION
<br />5Nr Route
<br />-loll.
<br />P.
<br />uww.s oEtos+10 E1iE1t:tN U.S.
<br />AIMED PORCES7
<br />ON, ow. p/if;,, IMP Sad d".w Si MsPiel )
<br />PART I
<br />N
<br />DEATH w . CAUSED IT.
<br />1-ad 44,1 C*YSR
<br />GINO Or BUSINESS OR INDUSTRY
<br />Rs ;;Home
<br />r!E1M tm two.,,
<br />:1V CP• 'ors Ol NO
<br />t1N fO
<br />STRUT AND NU
<br />11,
<br />*Au MOTHER —MAIDEN NAME 100, 4.000
<br />Peters Sawa Hazel
<br />1.441
<br />INIORMANT ►#+RMlCi» RIDATT0NS0MlAD1410: i001D35 111111, 00 4.1.0. 410 , cN. al
<br />,. Albert Moeller Jr. ate #2 Grand Island,` Ne 68801
<br />(ENTEI OMY ONE CAUSE PER LANE
<br />totrauma to body byftre .
<br />but 10, of M0 . CONNONNC? Ow
<br />COwN,wus;:'N STATE"
<br />TOE it pl. AND
<br />till
<br />.NiCN sa,. 14411 Ni ai cab Of straight truck becoming P g1,,1 fe in
<br />1•.a5sl.ts 4lI! ia. Ol. so
<br />,N1 . as as . epwl.Ow.1,c. w
<br />11.t11a IVINa C.li! tat, �
<br />(!, one vehicle accident
<br />P4A1T:N : 1The1ESIGssHO.. CON m0,4S cONOIr-0NscONTO•UTING TODEATNiUt:NotRE ATt11:
<br />TO CAUSE. CA/EN:IN POET::bri •
<br />ACCIDENT. sUICR,1E. HOMICUE.
<br />DATE OP INJURY ...ion., yr. Visa 1
<br />`«DET,a Ezl 7/25/76
<br />ItouitT AT wan t!UACE O NAVE!r a0• I. mi., N«., Asc:alV.
<br />I IaPCon ISA aa,::}W I :.; o1w0 sac . sK 1 sK+n 1
<br />street
<br />If* no " BR
<br />CERTWICATION... r11•0111 441 0140
<br />PHYSIe1.1N
<br />.3C at *1.0*D <h11
<br />74 •O*Oasi0 tilON
<br />TO
<br />CSEIlliCOMON4NEOICAVEWRINVI 00 CO1ONER:
<br />SlarwslsON M IIIS .l 0 *.i0/O0 Tat N11131104110N. N.
<br />OSAM::O0CTMS0 1M *pare" a.1. 0w t0 art craws;
<br />TTl
<br />COMER —NAME ones oe Nino,
<br />,,. Sam Gri nlmi nger
<br />BrAtING ADORESIThf
<br />west First
<br />CIEIMAlION RiM0VAl [:PuETIIT 0* CUMA
<br />1 won :r.
<br />)3urial
<br />iT/RE a'uCENSE NO. D y`
<br />HOVE
<br />1:40p
<br />PhAM NA 11MML wAs THERE A
<br />.O*ONAPECY 114 THE PAST S MONTHS?
<br />YESO NO QC
<br />see0CHISOA E 10.14114041
<br />Ms0..M Oast/ 404 01A1N
<br />AUTOPSY
<br />1nsmN01
<br />« no
<br />$ YES •EN CPU.ikrr,
<br />aCO
<br />Mde IN 01HTa-1Nwa ra,yr
<br />ea Naar
<br />Iw
<br />MOW Ili Y C I t ! 01 iN/la1 iN Pal, / O• PAU 11 1Nr Il
<br />LOSS 1 rEVOI r. er
<br />bux-c S rom ve c e accident
<br />LOCATION
<br />„E liiai aav'" 281 & 1 . 2 G, Nebraska
<br />REGISTRAR sIONA
<br />T~
<br />TNT
<br />•. NO.. CM OR la./is, SIA111
<br />I mime Nov ,.I1 tat DEAN OCCUNI 0 Al 114 rum 01. 11M
<br />E!1S1 Ara to Alt lllr .. .
<br />Ot ala ORINui0i' Eltl;.
<br />M robot CIOUI WOW
<br />SOS? MISS Olsen !Nall,
<br />TTE IT.
<br />1N. ascwll:r wN ./a1101F.C/a Na0'
<br />215, 1'9 7'1
<br />•
<br />�x
<br />2:1"' p.
<br />id sland , Ne 611801
<br />Orr es rows.
<br />,., Grand Island, Ne. 68801
<br />7a.
<br />M
<br />CO
<br />
|