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1� I_ :M Q U 3120 Ave "K" Council Blurts Iowa D13vi 1. EMBALMER - SK*iATuRE 6 LICENSE NO. 21 a AIE7HOD OF DISPOSITION 21D. DATE 6/16/2000 Not Embalmed ❑ eler ❑ R"1pNy 21d CEMETERY OR CREM $ FUNERAL HOAE -NAME John A. Gentleman Westside CH Cra"Is n ❑Dmlaon 2y FUNERAL HOME ADDRESS (STREET OR RF.O NO.. CRY OR TOWN. STATE DPI 1010 No. 72nd St., Omaha, Nebraska 68114 A u w (ENT(/�/�i ONLY ONE fR LIE FOR Ill. NN. AND ItN 'PI'"'®1A'i A;i11 l..o,�n'I, /1/�.1 I l A Ae16 A 21c CEMETERY OR CREMATORY nnaae Forest Lawn Crematory !ORY LOCATION CITY OR TOWN STATE Omaha, Nebraska 1 MrarvaObeleal n cruel and seam 0asrvsl bar~ duel and seam I I IMI `'W %W a -W %'" V — -'r I 1111et"M dn«i and NaM DUE TO AS A I I OTHER CONDITIONS - b tlu dead Wit n01 rOYNd PART M IF FEMALE WAS THERE A 2• AUTOPSY 25. CA D TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS/ EXAMIN OR COFIONER� tl IAY« 10-5+) Y« No r« No Ya6 No 26a 260. DATE OF INJURY (Aft. OW. YrJ Uc. HOUR OF INJURY 2Sd DESCRBE NOW INJURY OCCURRED Accdra � lAldeurmtud M Sucde Pe110i1q 250. INJURY AT WORK 261. P �F _6Ulat f .!arm. etael Ismy 264 LOCATE STREET OR 0.F .D. NO. CITY OR TOWN STATE aIldnK dt W-VOPI . r« ❑ NO ❑ ••••q► ^7( DA`TT�E /,OAF DEATH AID GJu.�ATE SIGNED !1!A:. Oar Yr; 26C TIME OF DEATH. DATE SIGNED � dl ..... ° i TMM�AF'DEATN �g[[ 26C PRONOUNCED DEAD lAb. atY, YO 260. pgONOUNCED DEAD (Howl 1L a n wam --led a 270 To M and 260. On eu llaau d exanwl«a+ mild d nwstgawn. , mY d0exon draltl 6 tl1t eft. del° end Glace aM due b M MMS(SI Mawd. and Title I ITS 0 30.o WAS CONSENT GRANTED( 29 DID TOBACCO U RIBU THEp — HAS OFIGIW OR TISSUE DONATION BE CONSIDERED ❑1. _ ❑ YES YES YES NO 31 NAME AND 4 OlE R S OR COUNTY ATTORNEY( /Type a PreWD a� r '7 10 67Yl�_& NF ,L,- - � ' 32D DATE FILED By REGISTRAR IAb DRY Yr.) 322 REGISTRAR -� -. JUN 16 2(x.0 This certifies this document to be a true copy of an original record on file with vital Statistics, Douglas County Health Department, Outs, Nebraska. Certified copies must have . - -_ —MI .M.M- - - - -- ---ai /twit° Ara mt -rnn m rry C1 Cl Z W = o Y 0 rn r-A o --1 O co --e M fl �! (n LL-1 zD� N Q- M ~ T O o O 1 m nT - M ty r W co ' f D co j C/) CD O CI1 W te6VE co Cn STATE i' .a,l'MDIT of 1�aTH Arm )MUM S E VWES FINANCE AM SU"MT 29 513 ti 2Q0113081 "�"L S` ""� C CERTMCATE OF DEATH FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH /A4ann OPY YOW1 I. DECEDENT NAME Marilyn Mae Demaray female June 16, 2000 t. CRY AND STATE OF BIRTH l/raln USA.. A&W 0de1017 50 . AGE - Lao Sw d" UNDER 1 YEAR LINDER I DAY S. DATE OF BIRTH IAaWeR DAY YOW1 se 4105 DAYS x IIDLms M6N5 Ewing, Nebraska "R' 69 February 15, 1931 7. SOCIAL.SECURIIY NUMBER &a. PLACE OF DEATH ® OTHER ❑ Nw"Home 508 -50 -3885 HOSM� wooll" ❑ ER OU OON ❑ Pas4w ce ❑ 8b FACILITY - Name !I na.WaAOn. pn Mew/and /MArlberl Clarkson Hospital ❑ DOA DowlsoewY III: CRY TOWN OR LOCATION OF DEATH Od INSIDE CRY UMTS Be COUNTY OF DEATH Omaha Y« Q No ❑ Douglas is RESIDENCE -STATE 9E COUNTY Bc. CITY. TOWN OR LOCATION od STREET AND NUMBER /Incn.Wg Zq Code/ 9e INSIDE CRV LWARS Ve° ❑ No Nebraska Hall Grand Island RR #1 Box 316 68801 10 RACE - It4. WMe. Black. A 11. ANCESTRY le 9 !Mean. M8-KV. Garmen, wi 12. [ ,'j MARRIED ❑ WIDOWED 13 NAME OF SPOUSE !ll wile 9n"e moden rwnel ec.;(5mc" (SOW -*) M NEVER DIVORCED Louis E:. Demara White German/Irish 14 USUAL OCICUPATION (GAw k"dd wort MW Aamy moo 1b KIND OF BUSINESS INDUSTRY 15 EDUCATION ISOtcWy o^IY ti91aNa 1X adcodnal EkwovArY or Sworto y 10 -121, Coate 11 -Aa5-� d aoraeq 6k ewlWnaredl Homemaker /Teacher Home Elementar 16. FATHER -NAME FF5T MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Walter Emil Woe 1 Elsie M ra IncCianahan 16 WAS DECEASED EVER IN U.S. ARMED FORCES? 19a INFORMANT - NAME nee no. o '&I n r« L►» wr a110 dr« a w.lw.l Russell WOeppel NO -_ _.- �...... .....r_ ervuccc !STREET OR 0.F.D NO.. CITY OR TOWN. STATE ZV) 3120 Ave "K" Council Blurts Iowa D13vi 1. EMBALMER - SK*iATuRE 6 LICENSE NO. 21 a AIE7HOD OF DISPOSITION 21D. DATE 6/16/2000 Not Embalmed ❑ eler ❑ R"1pNy 21d CEMETERY OR CREM $ FUNERAL HOAE -NAME John A. Gentleman Westside CH Cra"Is n ❑Dmlaon 2y FUNERAL HOME ADDRESS (STREET OR RF.O NO.. CRY OR TOWN. STATE DPI 1010 No. 72nd St., Omaha, Nebraska 68114 A u w (ENT(/�/�i ONLY ONE fR LIE FOR Ill. NN. AND ItN 'PI'"'®1A'i A;i11 l..o,�n'I, /1/�.1 I l A Ae16 A 21c CEMETERY OR CREMATORY nnaae Forest Lawn Crematory !ORY LOCATION CITY OR TOWN STATE Omaha, Nebraska 1 MrarvaObeleal n cruel and seam 0asrvsl bar~ duel and seam I I IMI `'W %W a -W %'" V — -'r I 1111et"M dn«i and NaM DUE TO AS A I I OTHER CONDITIONS - b tlu dead Wit n01 rOYNd PART M IF FEMALE WAS THERE A 2• AUTOPSY 25. CA D TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS/ EXAMIN OR COFIONER� tl IAY« 10-5+) Y« No r« No Ya6 No 26a 260. DATE OF INJURY (Aft. OW. YrJ Uc. HOUR OF INJURY 2Sd DESCRBE NOW INJURY OCCURRED Accdra � lAldeurmtud M Sucde Pe110i1q 250. INJURY AT WORK 261. P �F _6Ulat f .!arm. etael Ismy 264 LOCATE STREET OR 0.F .D. NO. CITY OR TOWN STATE aIldnK dt W-VOPI . r« ❑ NO ❑ ••••q► ^7( DA`TT�E /,OAF DEATH AID GJu.�ATE SIGNED !1!A:. Oar Yr; 26C TIME OF DEATH. DATE SIGNED � dl ..... ° i TMM�AF'DEATN �g[[ 26C PRONOUNCED DEAD lAb. atY, YO 260. pgONOUNCED DEAD (Howl 1L a n wam --led a 270 To M and 260. On eu llaau d exanwl«a+ mild d nwstgawn. , mY d0exon draltl 6 tl1t eft. del° end Glace aM due b M MMS(SI Mawd. and Title I ITS 0 30.o WAS CONSENT GRANTED( 29 DID TOBACCO U RIBU THEp — HAS OFIGIW OR TISSUE DONATION BE CONSIDERED ❑1. _ ❑ YES YES YES NO 31 NAME AND 4 OlE R S OR COUNTY ATTORNEY( /Type a PreWD a� r '7 10 67Yl�_& NF ,L,- - � ' 32D DATE FILED By REGISTRAR IAb DRY Yr.) 322 REGISTRAR -� -. JUN 16 2(x.0 This certifies this document to be a true copy of an original record on file with vital Statistics, Douglas County Health Department, Outs, Nebraska. Certified copies must have . - -_ —MI .M.M- - - - -- ---ai /twit° Ara mt