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� - 99 106306
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br /> DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO $� A TRtJE COPY
<br /> OF AN ORIGINAL RECORD ON FILE WITH THE STATE I�E,����:',ty�, HEALTH
<br /> BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL^'�?EPOSITUR�' FOR ,
<br /> VITAL RECORDS. � �` �
<br /> A ,.:..
<br /> / " Fi.J
<br /> DATE OF ISSUANCE .` ,� a
<br /> , G`�
<br /> SEP 7 �� STANLEY "S�1 .GOOF�k,; DI�,�TOR
<br /> ,�:,, .. .,.. .�,.�
<br /> LINCOLN, NEBRASKA BUREAU 0� •�"r P��A�'�STTCS
<br /> , ..�;, .
<br /> STATE OF NEBRASKA-DEPARTMENT OF HEALTH
<br /> BUREAU OF VITAL STATISTICS
<br /> CERTIFICATE OF DEATH
<br /> 1.DECEDENT�NAME FIRST MIDDLE LAST 2.SEX 3 OATE OF DEATH (MOnflr.Day.Year/
<br /> Inez Pauline Beliel Female August. 20, 1990
<br /> �.CITV AND STATE OF BIRTM /Hnof m U.S.A.,nams countryJ Sa.AGE-Last BinhOay 6.DATE OF BiRTM �MOntlr,p�y.Yea)
<br /> (��s.l 5C. MOS.i DAYS Sc.HOURS� MINS.
<br /> � Gr�nd �sland., ,Nebraska 78 ' March 16, 1912
<br /> �7.SOCIAL SECURITY NUMBER 9a.PUCE OF DEATM I �
<br /> HOSPITAL: (�Inpa6enl ❑ER Oulpauent ❑Dpq
<br /> 5 0 7-4 2-3 9 9 4 ' THER O Nunmy Homs ❑HewAenu �q�e,�gpki�.�
<br /> �D.FAqUTY-Nams /M nof naMUllan,gne ahest and numWrJ &.CITV,TOWN OR LOCATION pF DEATM 8A.INSIDE CITV LIMITS 8e.COUNTV OF DEATH
<br /> (SpsCAy Yes a No/
<br /> Clarkson Hos ital Omaha, Yes Douglas
<br /> 19a RESIDENCE•STATE 9D.COUNTV 9t.CITV.TOWN OR LOCATIpN 9y.STqEET AND NUMBER pneludmy Zip CoCSJ 9�.INSIDE qTV LIMITS
<br /> lSpecAy YN a No/
<br /> Nebraska Hall Grand Island 2408 N. Grand Island es
<br /> '70.MCE-(e.g.,Wh�ro,&uk,Mrwr�can InAOn, t t.ANCESTRV(aq.,hafi�n,MsMiun,Gsrm�n,stc.� �2.MARFIED,NEVER MARRIED, i 3.NAME OF SPOUSE (M wih.g�w rtuMm n�m��
<br /> Mc.l(SPk�'l /Spsc�iy) WIpOWED.DIVORCED(SpseiHl
<br /> White American �" Married Llo d Beliel
<br /> 1N.USUAL OCCUPATION(Giw kin0 d wak Cpro tluriip mpsf 1{b.KIND OF BUSINESS INDUSTRY
<br /> d Mvrk�irg IiN,svsn i!ntiroCJ Ebmsnta or S�epya 0 12 i
<br /> Housewife ��� ?�.� ry12 ry�- � co��.,,-•as,�
<br /> Domestic
<br /> 16.FATIiER-NAME FIRST MIDDIE UST 1�.MOTMEH-MAIDEN NAME FIRST MIDDLE UST
<br /> Grant Mc%ni ht So hie �lendt
<br /> 1B.WAS DECEASED EVER IN U.S.ARMED FORCES? 19.INFORMANT-NAME•MAILING ADDRESS �STREET OR R.f.O.NO.,CITYA�ID/YpSTATE,ZIP)
<br /> (Vn.no.a wNc.) (M yes.9iw wa ana dWS d wrvksa� VODVJ
<br /> No Llo d Beliel 2408 N.Grand Island Ave. G.I. NE
<br /> 20a BURIAI,CromaUOn,RSmovsl, 20D.DATE 20c.CEMETERY OR CFEMATORY•NAME 20tl.LOCqTION CITV ON TOWN STATE
<br /> Donaoon
<br /> Burial Au . 23 1990 Westlawn Cemeter Grand. Island Nebraska
<br /> t1.EMBA -SH3NATURE 8 LIC N0. 22.FUNERAL HOME-NAME AND ADORESS �STREET OF R.F.D.NO.,CITV OR TOWN,STATE,ZIP)
<br /> � ���'�+" ���8 A fel-Butler-Geddes 1123 W. 2nd G.I. NE. 68801
<br /> ��T IMMEDI E CAUSE �ENTER ONLY ONE CAUSE PER LINE FOR(e�,�b�,AND�c�) i Imerval bstween onsst antl C�aM
<br /> ' lal l�� . �'ul� .���'�tl� T"tn.�-'o�t.� �
<br /> DUE TO OR 5 A CONSEpUE E QF �
<br /> � �l,�tu�'vC-C � imsrvai bsiween onss�a�a aam
<br /> ti-�'r�-�- L._SZ.-- �
<br /> DUE TO.Oi�AS C NSEOUENCE OF: r� i Interval Detween onaet anC Eeatn
<br /> -'_ . ._._ - ./ - ...
<br /> . . _.a I . .. .
<br /> l.(.�(_.� ti'�.i i
<br /> P�OTHER$IGNIFICANT C DITIQNS- 0ions 'EWrp b G��aM bp nd rolr�ed PART III IF FEMALE.WAS 7HERE A 21.AUTOPSV 25.WAS CASE REfERRED TO MEDICAI
<br /> PREGNANCV IN THE PAST 3 MONTHS?
<br /> x �� � ;I� ; � /Specity Ves or No) E7fAMINER OR CORONER?
<br /> � ' � " ���"� Vea❑ No � lSpecity Yes or No/
<br /> 26a ACCIDENT.SUICIDE,HO ID ,U OET., 28b. ATE OF I URY (MO.,Day,Yr.J 28c,HOUR OF INJURV 28E.DESCRIBE HOw INJURV OCCURRED �
<br /> OR PENDING INVESTIGATIpN (SprdlyJ
<br /> �2M.MJURY AT WORK ZM.PUCE OF INJUHY-At lioms,hrm,slreet,faetory, 26p.�OCATION STREET OR R.F.D.NO. CITV OR TOWN STATE
<br /> lsv��r Y�+a na� anoe eu�a�nq,ma /sPSeny�
<br /> 27a.DATE OF DEATM �Mn.,pay,ri.J 2Ba.OATE SIGNED �MO.,Day,Yc) 280.TIME OF DEATh
<br /> a Au ust 20 1990 a��
<br /> , �Y 270.DATE SIGNED (MO.,Dty.Yr� 27a TIME OF DEATM 2&.PqONOUNCED DEAD IMO..LYy,Yr.) 28C.PRONOUNCED DEAD (HOw/
<br /> G
<br /> � � Au ust 22 1990 1725 P ����
<br /> �� s� 270.To YN Wq ot krowNOp� rrW at ths lima,tlata anE placa and tlue to ths E 2Ee.On Ilie basis of ezammatwn antl%or mvest�gauon,�n my oqnion tleath oecurre0 at
<br /> uu�a)ftaNO � / ��� Me nme.ONa an0 place anC due to the causels�auteC.
<br /> 8i ntlun arW Ti � '
<br /> IS naNre anC Tltla
<br /> �2Ya qU TOBACCO USE C TRIBUTE THE EA H 30a.HAS ORGAN OH TISSUE DONATION BEEN CONSIDERED? 30E.WAS CONSENT GRANTED?
<br /> I , O VES O NO KNOWN ❑YES' p NO ❑YES qy0''
<br /> 31.NAME AND ADDRESS OP CERTIFIER(PHYSICAN,CORONER�S PHYSICAN OR COUNTY ATTORNEV� (Type w PnM)
<br /> Vincent F. Miscia M.D. 465 Doctor Bld . N .Tower Omaha NE 68131
<br /> 32a REGISTMR f 32D.DA7E FILED BY REGISTRAR �Mp..Dey,Yr./
<br /> �� . M.P.N. . Au� s o tsso
<br /> � � oZ
<br /> Pease record and index this certified copy of Certificate of Death against Lots Thirteen (13), Fifteen (15)
<br /> and Eleven (11) in Block Three (3), College Addition to West Lawn in the City of Grand Island, Hall
<br /> County, Nebraska, EXCEPT for that part of Lot Eleven (11), College Addition to West Lawn in the City
<br /> of Grand Island, Nebraska, Hall County, Nebraska, conveyed by Warranty Deed dated April 6, 1957,
<br /> and recorded in Book 120 at page 525 in the Office of the Register of Deeds of Hall County, Nebraska,
<br /> and EXCEPT for that part of Lot Eleven (11) , College Addition to West Lawn in the City of Grand
<br /> Island, Hall County, Nebraska, conveyed by Warranty Deed dated August 12, 1958, and recorded in
<br /> Book 125 at page 117 in the Office of the Register of Deeds of Hall County, Nebraska .
<br />
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