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CRY A <br />RAISED SEAL OF STA7EOF THEoocuMe4T mow TO <br />L RECORD ON FILE WITH * NEB ;1 ENT OF HEALTH AND <br />VITAL RECORDS OFFICE WINCH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES <br />off%qfT ; <br />Lest euE*I <br />te WRY, OR POREI8N COWARTOP BIRTH <br />PECILITTAREE Ut eat pwaddlaM1. a vs West and number) <br />4 11 SEW <br />fa,REMDENrE4TATE <br />i pCads) <br />I <br />Ob. COUNTY <br />Hall <br />ETA le R TIME OF DEATHH ❑ Welled 0 New Vented <br />• QM.m.* but sweated ❑Widowed ®Diverted QUnknown <br />TY <br />Middle, Lea, Suffix) <br />EVE T"^4. = Give dates of swipe I Yea <br />(Y.. Nsk or laic) Yes 11/1411969-0611611972 <br />PART LLewPmOMRof <br />limns/ Igurf MIR MGd <br />wmoll MIME •ee.a DUE To. oRAsA[rWtayalW :OF: <br />Sa AGE '• Last Sba <br />lYea) <br />�► UNall1 YEAR <br />s Sac <br />Male <br />faUNDER 1 DAY <br />MOB. <br />DAYS <br />0 issoidpiowit <br />N. CITY ORTOP N <br />GrsaO.I <br />HOUM <br />NINIL <br />DATE r1RDU <br />November 6 <br />I. DATSOF MTh Dot Yr. <br />Ociober30, <br />VI <br />OTHfiR. 0 NursingHsmY1.TS <br />Ira <br />❑ D.sds t s neat <br />Q Other Iaselltyl <br />Ild, COUNW OF DEATH <br />Hall <br />W. SP CODE <br />68801 <br />11)b.WMI OF NOUSERek MIddIA Len, eosin M MCI, SIvenWdlraeae <br />33;;�� <br />14e. INPORM NTAIA <br />MIMI Carr <br />1e► dISIM UBR-MOWITURE <br />Not Embalmed <br />11111.CEMETERY, CREMATORY OR UTHE OR ATION!<„- <br />Central Nebraska Cremation Services <br />MI1n1NSADDRde tared, WS et Tow. ) r4a <br />, 2929 S. Locust Street, Grand Ndaaa +Y <br />14ENSE NO. <br />Maas, WSW eeaeeV) <br />rs <br />1¢ RELATION <br />Daughter <br />1N: DATE ON, <br />November 7 <br />COY MEM <br />Gibbon <br />CAUSE OF DEATH Mee IDAtrudldEh antiontamolest <br />/ledw, etlrbd, rr,glutMerrr Ow* SUM ore des6Da NOTrIbrimMel owes awl r crews IRMI. <br />*god RomigGasedeey DO NOrAaasgMeR NOR co Ono mow an#ele.Add seildrl RIM Wlwawri <br />TE CAM: <br />sepsis With pneumonia and boVret <br />DUE TO, OR AS A tONSEOUENCE CC: <br />b) <br />0ONDnwxe-Comlbthe Iota lbdana teas WOW* <br />Sam <br />Eet*ORA • MWMdmMwMlt days vilest <br />❑ NrryvpadL MdnMIMRN dyi,te 1 yew N MdM• <br />0 <br />WA RUM AT WORK? <br />Its. MANNER Or oda <br />® ❑ <br />❑ Malin* ❑ <br />❑WY ❑Plied NONie.Ned <br />!!b. rare a NJLMY <br />RUMOR, APT. NO. Cr1YsTOWS <br />OIL.DATE OF DeATH lee, Day,. Yr.) <br />} Novae,.. 2 <br />The Wut Yee, MD <br />The `r Yee, <br />SIGNATURE <br />dr• w.wd MN* Sete die.... Aro <br />RlpNswsed11(w <br />Yo TH! DEATH? tea HAS Gamut ,.. . <br />LY UMIMOWN ❑Yea <br />OFDEM (Tweet )) 5 ,., Wr• <br />�;.. <br />W Feldley Ave, Grand Island, Nebraska, 88603 <br />Oval In PART L <br />eW DATE OICDIED Ma. Dry. Yr.) <br />APPWYtN11TE <br />1e. WAS <br />ON COIIDNat <br />'QYes NO <br />S1t. WAS'AN AU <br />❑ YEE NO <br />21d. W611! AUTOPSY MOMS AVIMI.A J <br />TO camera comes OF MATEY <br />❑ YES ❑ , <br />EIGRAiandolan• mitt -V4migelleR RR**. <br />• Verd and Nobs Nl.p oast Ovum NG <br />d3+ElC.«T. <br />GIN. WAS CONSENT <br />Ma Applicable 1 EN Is MO <br />Web. DA1! FRED W REGISTRAR <br />November 13, 2023 <br />810 <br />