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WHEN THIS COPY CARMES TFE RAISED SEAL OF THE NEBRASKA HEALTH ANb ft&nWvI'`ES <br />SYSTEM R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECPW N FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST,SjIICH is <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE_ <br />DEC 10 2003 200402091 <br />A3/ST,411Is <br />LINCOLN, NEBRASKA HEAL THA AISERVktgSsvxr€w <br />Sli1�6!'1Blt- 1'>11Aliil! <br />(] 1 <br />T• - <br />m <br />A_ (y <br />L ABIaFmow <br />V -tar + <br />\ ('AU p! GAYS <br />SC lq{�' ttfls. <br />mom <br />Jul 31 1 <br />t <br />M. PUCE Or OMTH <br />I4oWFTrAI ❑ t.atar ❑ NuMq HMn. <br />F Y -Nt/Aa al„yrallyrNLjgMN1a1I.Aaaa4f ❑ ER Ommim Im it p . <br />j <br />❑Dow ❑ ar. rSAM y1 <br />at UTY TOM OR C11T10N RA OF TH <br />IN INSIDE CITY LOWS w COUNTY OF DEMN - <br />AN <br />1 <br />ft NIMMENO140W gI COUNTY <br />8tl Cm. TOWN10"LOCATRON We. STREETANDTWW Lm *c"4 '3pcxWfM3 84 mmmc TYUURS <br />1 <br />Mbraska Hall <br />Grand Island 2519 W. Charles St. T"r ®� ❑ <br />�M MCE- VAft5 Ck AffW.MYWn ,,. ANf:B671N Iaq.. <br />C>-4 <br />n <br />c <br />I r. <br />wu O�Ai nllp 44Naa«4ad,►A141parlt <br />1 <br />IEYER ORPOWED i . <br />TAO IONDOf011SWmmmuSTRY ,s EDUCATgN 1 c«11FN4Np <br />8aoMltlrY <br />ftedwtion Worker <br />Monforts seat packing) a Io ,xi earpa I, a M 5.1 <br />z <br />n <br />CA <br />Roc ero <br />WAS DE+CEASM E11ER N US AM= FOR= <br />Na yNKMAINT -NATE <br />(YIK no a,M►I a,.t a»wrra.r.aKRnw, <br />M <br />No <br />Ift wooftwo LIAtM 1STTTEET CA off 0. NO- CITYORTOMSTATE.2N4 <br />2519 W. Charles St. Isla <br />, <br />a <br />*1212 <br />�• 4ETHOODFOWOSrtION 21C. DATE; 2te. CEMETERYORCREMnTCRY NAME <br />' <br />❑ O" [OR-- <br />"" OA CREWTOW LOCATION CITY OR TOWN STATE <br />na FLOAlo L1(OY -1 <br />fel- Itler s F. H <br />0.8 <br />❑ `..N. ❑ O.W <br />IIO1E AD A— B QR rf.D ND. a"fiY OR 1,3AN. STATE. 2tP1 <br />23 W. Second St., <br />AWL" <br />cil <br />VWFMONLY ONE CAUSE PER LNE AR. L" aavlrr Narlatn o14r any euln <br />I <br />� <br />DUE TO. OR AS CONSEQUENM <br />Natnlr ushvWo tal wo am" <br />DUE TO. ON AS A CONSEQUENCE OF <br />re OaN,Mnonmanydmpl <br />tI ICI <br />r <br />125 <br />Ijil <br />N ,`r� <br />�v <br />ys LTO <br />ft" 10 -541 YK .Vql YK No YK NO IR <br />284 Mb DATE OF NAMN rb �Da,. YrJ 2k HOUR QF NANY 28tl DESCWSE NOW WARY OCCURRED <br />AcC1K1a m4ow11MNtl <br />S-ft pow. 1p IWa 1NAAW AT WORN M <br />:3 <br />f D <br />1 272. DATE OF DEATH rlu Csy Yt.1 <br />24 DATE SIGNED 10* GIr rrI <br />280 TIME OF DEATH <br />if <br />DI1TE 9gNED !W. D/r Yrl 27e TIME OF DEATH <br />W <br />�C <br />s- (e -g? <br />lig <br />11 271 TToft 1MM10. MSr .tl. anyaN* am A4 *we <br />D <br />IM wK. Of OW PIN* aM OW b 90C& MM Mtl <br />IS1 MM4 antl Talc <br />antl T <br />Za. DID TOBACCq U8E CgITipSUTE TO THE MAT M <br />Spa HA8OROAN OR TISSUE DONATION SEEN <br />CONSIOERED� <br />300 WAS CONSENT GRANTED' <br />Ca <br />❑ TES <br />NO <br />n YES I1NL No <br />WHEN THIS COPY CARMES TFE RAISED SEAL OF THE NEBRASKA HEALTH ANb ft&nWvI'`ES <br />SYSTEM R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECPW N FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST,SjIICH is <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE_ <br />DEC 10 2003 200402091 <br />A3/ST,411Is <br />LINCOLN, NEBRASKA HEAL THA AISERVktgSsvxr€w <br />Sli1�6!'1Blt- 1'>11Aliil! <br />(] 1 <br />T• - <br />amp <br />x welt x w.e, cl�; n.ai , - _ <br />, l 4K TM/ <br />L ABIaFmow <br />V -tar + <br />\ ('AU p! GAYS <br />SC lq{�' ttfls. <br />mom <br />Jul 31 1 <br />t <br />M. PUCE Or OMTH <br />I4oWFTrAI ❑ t.atar ❑ NuMq HMn. <br />F Y -Nt/Aa al„yrallyrNLjgMN1a1I.Aaaa4f ❑ ER Ommim Im it p . <br />r <br />❑Dow ❑ ar. rSAM y1 <br />at UTY TOM OR C11T10N RA OF TH <br />IN INSIDE CITY LOWS w COUNTY OF DEMN - <br />AN <br />1 <br />ft NIMMENO140W gI COUNTY <br />8tl Cm. TOWN10"LOCATRON We. STREETANDTWW Lm *c"4 '3pcxWfM3 84 mmmc TYUURS <br />1 <br />Mbraska Hall <br />Grand Island 2519 W. Charles St. T"r ®� ❑ <br />�M MCE- VAft5 Ck AffW.MYWn ,,. ANf:B671N Iaq.. <br />IRM MK4sn.6MwMLM3 ' ,x. ®m ❑ WIDCNED N1wY D.+4r1AP1ArNA1 <br />4M, ftm*A E3 <br />113NAMEOFSPOUSE <br />I r. <br />wu O�Ai nllp 44Naa«4ad,►A141parlt <br />1 <br />IEYER ORPOWED i . <br />TAO IONDOf011SWmmmuSTRY ,s EDUCATgN 1 c«11FN4Np <br />8aoMltlrY <br />ftedwtion Worker <br />Monforts seat packing) a Io ,xi earpa I, a M 5.1 <br />f -HARM FIRST MDOLE <br />IT MOTTM fNST NKME UNDEN SURNAME <br />Pedro <br />Roc ero <br />WAS DE+CEASM E11ER N US AM= FOR= <br />Na yNKMAINT -NATE <br />(YIK no a,M►I a,.t a»wrra.r.aKRnw, <br />No <br />Ift wooftwo LIAtM 1STTTEET CA off 0. NO- CITYORTOMSTATE.2N4 <br />2519 W. Charles St. Isla <br />, <br />a <br />*1212 <br />�• 4ETHOODFOWOSrtION 21C. DATE; 2te. CEMETERYORCREMnTCRY NAME <br />' <br />❑ O" [OR-- <br />"" OA CREWTOW LOCATION CITY OR TOWN STATE <br />na FLOAlo L1(OY -1 <br />fel- Itler s F. H <br />0.8 <br />❑ `..N. ❑ O.W <br />IIO1E AD A— B QR rf.D ND. a"fiY OR 1,3AN. STATE. 2tP1 <br />23 W. Second St., <br />AWL" <br />x3. PART � WrMTE CAUSE <br />VWFMONLY ONE CAUSE PER LNE AR. L" aavlrr Narlatn o14r any euln <br />I <br />� <br />DUE TO. OR AS CONSEQUENM <br />Natnlr ushvWo tal wo am" <br />DUE TO. ON AS A CONSEQUENCE OF <br />re OaN,Mnonmanydmpl <br />tI ICI <br />r <br />125 <br />PMT OTHER S16W0447 CONOIROIp - CMltlaas=M A Fg1b 614 (MM Ea4101~ PART III f FENIALE WAS THERE A ?• AUTOPSY WAS CASE REFERRED TO MEDCM <br />N ,`r� <br />P EGNANCY N THE PAST 3 MONTHS' EXAMINER OR CORONER+ <br />Wire— <br />ft" 10 -541 YK .Vql YK No YK NO IR <br />284 Mb DATE OF NAMN rb �Da,. YrJ 2k HOUR QF NANY 28tl DESCWSE NOW WARY OCCURRED <br />AcC1K1a m4ow11MNtl <br />S-ft pow. 1p IWa 1NAAW AT WORN M <br />tP1n fUa41 NCWV 2% LOCATION STREET OR R F 0. NO CITYORTOWN STATE <br />D4 4S d[ !MP«yl <br />❑ 1lynwnta tnraplgltNn rK � No ❑ <br />1 272. DATE OF DEATH rlu Csy Yt.1 <br />24 DATE SIGNED 10* GIr rrI <br />280 TIME OF DEATH <br />if <br />DI1TE 9gNED !W. D/r Yrl 27e TIME OF DEATH <br />26C PRONOUICED DEAD A* Cry' Yt I <br />28d PRONOUNLED DEAD Mater <br />s- (e -g? <br />lig <br />11 271 TToft 1MM10. MSr .tl. anyaN* am A4 *we <br />>r DnMKMaarnllron any «YNMXgrPn..I lnpyWlgn K4P'occlmtl■ <br />IM wK. Of OW PIN* aM OW b 90C& MM Mtl <br />IS1 MM4 antl Talc <br />antl T <br />Za. DID TOBACCq U8E CgITipSUTE TO THE MAT M <br />Spa HA8OROAN OR TISSUE DONATION SEEN <br />CONSIOERED� <br />300 WAS CONSENT GRANTED' <br />❑ YES NO ❑ UTA(NDWN <br />❑ TES <br />NO <br />n YES I1NL No <br />31 NAME AND ADDRESS OF CERTIFER IPWSRCWL ODRDNER S PHYSIOYW OR COUNTY ATTOIMIEv, jrmel r pfwj <br />LFCAL DESCRIPTION: LOT ELEVEN (11) IN FRACTIONAL BLOCK NINE (9) IN ASHTON <br />PLACE, AN ADDITION TO THE CITY OF GRAND ISLAND, HALL COUNTY, NEBRASKA <br />o rn <br />N <br />O <br />O <br />O <br />N <br />O <br />CD <br />`.I <br />�c <br />