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. 99 106485
<br /> , Aev �ti9� STATE OF NEBRASKA-DEPAR'IMENI'OF HEAL'IH AND NUMAN SERVECE3 F[NANCE AND sfJPPO1tT
<br /> VITAL STATISTICS
<br /> CERTIFICATE OF DEATH
<br /> t OECE�EN7.NAME FIfiST MtDOIE US7 7 SEX � OA7E OF Dl11TN iA4rMr D�r YN.I
<br /> Edward Thomas Lane Male March 17, 1999
<br /> � Cltv ANO S7�iE Of B�ATH ql nel h U S�..rorrr�eaunhyl L AOE-UM BIrIM�y UNDER 1 YEAR UNpEq t DAY ! AI!Oi MAiN / r v�
<br /> Arcadia, Nebraska "'"' 79 � �s � o��g Se HOURB' MtN$
<br /> October 25, 1919
<br /> 7 SOCi�I SECURi1V NUMBEA !a PUCE OF OEATH —
<br /> SOS-18-4500 H09FITAL• � ��o.«.�+ o?�n � w,,,.��,,.
<br /> . _
<br /> Eb FAC0.ITV.N�nM n�,�,m,m�,�,a».r...,.,�,�,„�e.� ❑ eA o�.x.M � w..e.�.
<br /> . St. Francis Medical Center ❑ °OA ❑ �«��M�
<br /> !t CITV TOWN OR IOCATIpN OF DEA7N !d.IN$IpE CITV LIM173 !s CWNiV OF pEATN
<br /> Grand Island �„ [� ^� ❑ Hall
<br /> 9� FESIDENCE•STAiE 9D COUNTV 9c.CITY,TpWNOR�OCATION gd giREETANDNUMBER nh�cklolYqlpCoicU/ 1�Nlqp(�RV�iu,+�
<br /> Nebraska Hall Grand Island 1518 N. Kimball 68801 �«� �❑
<br /> f0 PACE�Is q.WhM1 81sc4�m�.l��n YMI�n. f 1.ANCE37RV Is p.tl�N�n.M�vkM.pqm�n.Ntl 12�M�RRIED Q W1pOWlD 1� N11MF Oi SPOUSE /I w+r p�v�bM rwr)
<br /> a�e I ISoecNyl ISoecMl NEVER DtVORCED
<br /> m White American Della Henderson
<br /> � ��� USUA�pCCUPAipN /Gns►�dMrdkobrwMYpmosl 1�D.KMIDOFBUSINE$SINDUSiRV iS EDUCATION �$p�Nly cpmpybA)
<br /> o d.o�r.y mtr..�r�M.sm
<br /> ?° Line Foreman Ordinance Plant E��t Grade �"'a���
<br /> la i11TMEN�NAME FIR3T MIDDIE UST 17.MpTMER FIRST MIDDLE MAIDENlVM7AYE
<br /> U �
<br /> Marion NrIIJ Lane Rose NrIIV Fa us
<br /> O • te WAS DECEA9ED EvEii IN U.3 ARMED FORCE39 t0a INFORMANT�NAME
<br /> `m IVw.no.a unw.l IM ya�.piw wv�M dehe d wrvkesl
<br /> s Yes 1942-1946 Kathi Mate ka Dau hter
<br /> � tYb INFORMANI MAILM70 AODRE33 ISTREET Oq R.FA.NO.,CITV OR TOWN STATE.ZIP�
<br /> X
<br /> � 4145 Ar Ave Gr Island Ne. 68803
<br /> Z � 'JO E MEN• K1N�7UAE 6 L E ��� 21t 1AETNOppF Olgpp&iqN plb.OAtE t1C C MCTfRV p1 CNE4AtOAV NA
<br /> e,Mr ,w,�,,., Mar. 19, 1999 Arcadia Cemeter
<br /> W E 7t� FUNERAI .NA O ild.C M T RV OR CAEMAiORV l 11TION GiY OR TpWN yfAtE
<br /> � �
<br /> v � Livingston-Sondermann F.H. ❑°�"°^ ❑�^�^ Arcadia, Nebraska
<br /> W � 22b FUNERAL MOME ADDRE9$ ($TREET OII R.F.O.NO_GTV OA TOWN.3T�TE,ZIV�
<br /> � L
<br /> O D 601 N. We�b Road, Grand Island, Ne. 68803-4050
<br /> � 7J IMMEdATE CA 3E �ENfEF ONLY ONE CAUSE pER UNE FOR 1��.�p1.AND loll MWvN Drh.Mn d»w n�e d�aT
<br /> Q � �'Ru� �S f�� �% 2 k'� '�1' /h�',��f.�
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<br /> z � DUE TO,OR AS A CONSEOUENCE OF � Mw�M MM�n arM r�e�.rR
<br /> � ,w Q(Zh 9.) l,-� l,v �
<br /> �?� �
<br /> OVE 70.Oi1 AS A CONSEOUENCE OF- � k�.vN orMM rw�daM
<br /> ��� J 0 w�c— � 'T��,.a ' l� -�� 0 ,�
<br /> GART OTHER SKiN1FICANT CONpT1pNS•CP�dNOns torhrbuM�p b IM AsNh bul nol rNNM PART NI IF fEMALE.WA$TMEHE A 7� AUTOO$V 2S.WAS G�SE AEF fp MFdC�I
<br /> M 7REONANCV M THE OAST�MIONTHSi � E)IAMINER ql COIq1�ER+
<br /> (Aa/10•S1� VN NO YN Np YN Np
<br /> ?E� 1lA.OAlE OF INJURY /ilb..W/.N.l '1lt,110UR OF INJUIIV Ild.OEBCIi18E MOW INJURV OCCUIMfD
<br /> � ��e�ASre � UMMe�mrneA M
<br /> � Su�eM� � O�Ming 2M.INJVRY AT WORK 2a1.PLAi E OF N.NNiy/�1�qpM.hrm.Mr�.�Klpr�, �Ep.LOCA�pN $TREET OR R f 0.NO. CITY Oq TONM ST�Tf
<br /> OO O o11k 6undnp.�le Sp�tey�
<br /> Hrnniuda Inver�pntion Vss No
<br /> II7� DA7E OF DEATH /Mb Ow Yr J �.DI1TE MONED /Mn ON Yi 1 !�E TIMC DlATM
<br /> , s �- 2 C-c:� i 7 /f S� S s w
<br /> ��� 77A DATE&ONED /Mb.OW.nl �7c.TIME�pEATH ���� 7le.PRpNOUNCED OEAD /Mn.dy.Yrl M0.MIOHOUNCEO OEAO p�b��i
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<br /> �ieN�l e1eNd b Mv Mm�.dN�oM 0���rM du�b M CMwNq�YYO.
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<br /> T9 OIO TOOACCO USE CONIIMDUTE TO THE OEATM7 �0.�HAS OROAN OR T108UE OOPIATIONlEEN CONNOERED7 �0 S WA CpNSE11T OIUNTf09
<br /> � O VES � NO � UNKNOWN � VE9 � NO � YE! � NO
<br /> �� NA�E_�N�AOOqE$$OF CEATIFIEq�pNY91CIAN,CORONER S PHVSIC N OR CWNTY AttORNEVI 17�a Priq
<br /> Dr. David W. Cockerill, M.D. , S00 Alpha St., Grand Island, Ne. 68803
<br /> 72� REC718TNAR J7U O�TE FREO SY REOISTMR �AAU.QM N.�
<br /> FOR VITAL STATISTICS USE ONLY
<br /> Place.......................A................................8................................C................................D................................E................................Part II........,.............TMV...........................
<br /> NSC...................................................................................:...............................................................................................................................................................Censua Trect No.
<br /> Work...................................................................................................................................................................................................................................................................................... ..
<br /> UC..........................................................................................................................................................................................................................................................
<br /> Reject..................................................................................................................................................................................................................................................
<br /> �r.���.e.nn wr��e�.�eyeaa�nr•
<br /> Lot 1, Block 83, Wheeler & Bennett Fourth Addition, Grand Island, Hall County,
<br /> Nebraska.
<br /> I hereby cer ., � ,.� __ ._ - _ ,.... � _�; �___ _� , ,� u; ���;� oria;nai filed with #he
<br /> Siate oi ��,�� ����;�a _�_
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