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I I <br />rri <br />M <br />ej <br />v � : 1 • O T 1 <br />m y 6 <br />W <br />Wf1EN 7M3 COPYGRRIES TIKE RAISED SEAL OF THE NEBRASKA HEALTH AND h <br />SYSTEM, tr CERTU7E3 THE BELOW TO BE A TRUE COPYOF =HEALTH RECD <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/STISS�S�1 <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATES OF ISSUANCE ASS6t� <br />LINE OI.N, NEBRRASKA 200402293 <br />NEALTHANlFVm^^ 9 <br />STATE OF NWHASKA- DEPARTMENT OF NEAL <br />a... of Vita StAWUu vr <br />CERTIFICATE OF DEATH -', � <br />T3€K <br />s" <br />R <br />R <br />° 70.02011 <br />1970 <br />MCI wnm, wtOrO..wwN rNeuN• ud -cur 0 W' ullm INwrrx. D• CoYMY d OGm <br />' nc. Inramr iWU•Irr•nr ND4. ..n NaINt nw. <br />Whits (ry . <br />M. <br />bat <br />CIIY. TDWN. ORL dCEAm mt. +scum MAL OE OmM - rmR4 em tn\n •ro Na'wrr <br />Wclry +esm XD <br />n. Y r!' n or wn,em R•WrN Nrnr <br />surf m , I. Xe, .N et..., N.NI clnxw d wxnr tau,+nv MAlaEO, NEVlE MAmEO, <br />cewrwl I4.N.arr <br />;nowln•awE[tO <br />U n. ring It' "Sa Homo <br />xDw e r <br />SOCIAI MCYaIY NUWf\ YwDwi\µrw �7wlbiNa oxwe er ww. w.r sWrNU EaID d aNRrESE d MrWSRN <br />YLRt•I <br />- i< <br />Ll- Ia. P law <br />.SIDENC! –E,A,E COVNIY CSI. TOWN• d tOCAIION C cm ram 3T\Br AND \ <br />I Wornt4 m Xer <br />Nebraska Ia. Ran IY. Grand <br />H.. <br />rAiNlE -xN,f nai .Ime un MOtNF11 -:w N NMY rmi xmlr '•n <br />Jacob Roane Il. Victoria <br />INIOaENlT– NAMf– lEIATIONSNIE tuamc AOD\E$$ w,an O. er.e. Xo., fm w roww, n•R, IMr <br />NS. <br />xAM I. mAm WAS GUS[O EY: IMI[i ONLY ONE CAUSf NR lRA id (aA IDL AIN RJI wrvaN omn Mo ww <br />n. caw <br />Acute adoeardial lnfarotion <br />10 minutes <br />.DNDnIg,•,y Arteriosclerotic cardiovascular disease, ears <br />iSd IsI <br />"unwAmr <br />. D w ro. o+ •s • cDNwonNw Dr: <br />r uNeii ° <br />�aii�no <br />a ume I ++r <br />Id Y G CMwv - <br />! iurrIw, NmOnrN NlN an O 4 G <br />I.F MtIx W iX [ w i X i ! !M! OA w d <br />i lqr g4ilD rn•ltn <br />C <br />Ma lo. t4 d <br />w lt6 .w 'Xw N <br />1 0also. <br />ow r <br />p !11w1N1!CV <br />fONa0r1neCtWion on 2�2W3w1W60 N!Y oAn ❑ <br />t• o <br />. <br />f{41Y1i 6 <br />o <br />IrYp awa <br />r r <br />\Nw <br />rM nN+ INN$ NxY <br />w rv.a r w •n <br />OCUE!!D 1 enr <br />==—, <br />A, M, ML <br />Ift N r. we on <br />INIU�Y AT WOM FlAC! u. tran..wrnr, IOCAf10N r tnm e..... .. eD recur, >GR <br />I W[In nt Or Wr OMNe WO..IS_wr.Onr <br />a.. 1N. rti rxw <br />4. <br />���` cur uw xN /xn ulw o. µnioW cur ww m in oceutaD •r we wn, w w <br />M nm_ senaro. A R,nN. ie A �,u R, <br />xnwx e•r n NwIN D•• iW nu xgLl. <br />N,w u <br />rmxr. ueel .70 TO 2 did : �O aM. +ie rn � w <br />216 <br />t 11 <br />-70 I <br />-17w64 -27 21, _ <br />t^Gm•i e�nrr:a« <br />rw M40 q ON Mw OI M.rx • ow�w» w•f rpX:Al� .D DYe Ytw MN <br />CEMRKATIClI- Kll�lfAMallt�TiE EO E_���� <br />tAWwtrIM Or M iDr �Ot IW OnrwWrox, w w OIw1eN, M. <br />DGrx OW @4rD aM nx aaR u OU ro mr GVUN tw »o. M. }II. <br />�� r <br />A wcnr q elm A Gi.OXM. mp w <br />-IINAE Inn 0. ONq 2- 2..70 <br />Richard F. M.D. a <br />M"'�o Ap°E °-c "r "E° 721 West Seventh 3 rand Island`rn t a raaka 68801 <br />lyeµ, plIM110\I, NPIOVAL <br />cal :1114 wn. w. 0rard Island, Ngbr <br />N. <br />I w,WM, m, ., lIINE \1! xOM!– ANC ACM[5! 1 sun e. ersTxD.. cRi w.o.w, n•n, nn <br />PAT. <br />w Mar, 2 1970 TN.� <br />- nlEe <br />BElA1MEN WNATIIM E UCENSE NO. <br />MlA �_ .. A– iRRD <br />