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WHEN TM COPY CANNES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, !f CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RED O FILE iA(ITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/ST8%§S CFi IS , THE LEGAL DEPOSITORY FOR VITAL RECORDS - 4 DATE OF ISSUANCE OCT 12 2001 A AfE R= LINCOLN, NEBRASKA HEALTH AII�}SERVICSTEII 200113625; STATE OF NEBRASKA — DEPAIM —WoT Of MALTA BUREAU OF VITAL STATISTICS�{ Cffi 1 !� 91 03192 W"MTE OF DEATH L qj J I- DECEDENT - NAME FfW mom LAST 2 SOL a DATE OF DEATH NMw^ OW.. Yo" _ Andrew M. Bial Male 03/22/91 6. CRY AND STATE OF M1M M naM U.SA. AMMMw omwo Sa ADE - W S. E DATE OF SMITH IMATwL Cry. y� (YMI 70. MOS. I DAYS Se. HOURS MSNS GRAM ISLAND. NE 68802 1 11/24/05 7. SOCIAL SMecURRT Nff Ml Sa PUKE OF DEATH HosPTTAt: 0- K DIVO.WMwM DO O A ao wAoft "w e 0 Rwtlw�n 0 Cow ,seed„ d FACO." - Non Awd MwMafMML YL+MNf rN ni /Mw) !t. CRY. TOM OR LOCATION OF DEATH ft 111510E CRY IIIfTS M. COUNTY OF DFATN ST FRANCIS A1. CENTER D ISLAND, HE A8801 Isoftoy YMr M. Aq YES HALL SA FIERCE - STATE Y0. COUNTY Po. CRY. TOWN OR LOCATION 6Q STREET AND MAXIM pr W&V ZIP CoMM) 9a YSIDE CRY MISTS Nebraska Ball Grand Island 110 E. 6th I mo7ey;-Awo IS. RACE - hS. YRwa Mao Awwcm M.fwt 11. ANCESTRY PCJMWL M -scan. Owlnwt wy a MARRIED,NEVER MARRIED. 1i NAYS OF SPOUSE AF.ek pw mwUm fia" w41000I l White l M American 06 wI owm DWORCEO /1ge 0 Married Eunice A. Darrah lk USUAL OCCUMTION 1bA'w awOdraR Arw AMmy nww dwaYv /mwaA laa IOND OF 9US94EN MOUSTW 10048"1070"t- ww Laborer I_ Construction Ott77 Mtwwy0 -121 I CMIM/MIt -4aS-1 10 1S. FATHM -NAME FN6T MIDDLE LAST 77. MOTHER. WIDEN NAPE FMT MIDDLE LAST Albert — Bialy is — Socha 11 M1w5 DECEASED EVER M US. ARMED FORCES? t0. INFOIIIANT . MAW . MMLDO ADDRESS ISTF"T OR R.F.O. NO- CRY OR TOWN. STATE ZIP) nM..w «w1�1 A71alMwwr Awn aw1w0N Eunice Bialy -110 E. 6th-(;rand Island, NE. 68801 20a SUMAL. Q14MMA/wawYML Mb DATE Oo1Wr 20C CEMETERY OR CREWTOW - YAME 20Q LOCATION CRY OR TOWN STATE Burial March 26, 1991 West-lawn Memorial Park Grand Island, NE. 21. - SffATl11E S O� FUNERAL NOW - NAME MW ADDRESS 1STREET OR RF.O. NO- CRY OR TOWN. STATE. ZIP) fel- Butler - Geddes 1123 W. 2nd Grand Island - NE. PAY IAN SSE WXTER ONLY ONE CAUSE LINE FOR W NL AM kll I YiwrNN Owlwen aww ane Or•1 T �P,E[R CQ.f t7. O .fG %� �s / DUE ra OR ArrS A OF: I M4wra1 bW~ onM ww O.M/I l7r7GP %fr ALL /� �iSrctl� ' Qom' S OUS ra OR AS A COM8EOUV= OF: Yiwww p ywMn OMM S d fun 1 ki SOMIRICANT Crlwlwr OwIMOWp w Alafl W n1N 0111„0 PART ■ IF FEMALE WAS TIIEFE A 1214. AUTOPSY 21 WAS CASE RL'�ERFIED To MEDIAL PREGNANCY M THE PAST 7 YONTNSY (SP«'+, YM1 «Ap EXAM04A OR CORONER? PART L/IF vs C • •GA.f-� p f./ 1 7— r« ❑ No ❑ N O 26a ACCIOSAX. SLSCIOE, HOMINGWAL UNOET. DATE OF MAMY (MILAW. VN 210. HOUR OF RAM 26a DESCFVSE HOW INJURY OCCURRED OR PENDMD WdUTIOATIO11 fAwa9T 2N. MANY AT WOIrI 2SL PLACE OF MANN/ - N OwM Nwat MML wewry. 265 LOCATION STREET OR RFD. NO. CRY OR TOWN STATE '. ^Mow YM W" alike M00%Ma Amogo zU _ 27a DATE OF DFATN 0196 08% Wj 21a DATE SIOMEO AMa Oat• W) 2M TSE OF DEATH Raw.'4 �? 2. X9 7 / j Ar EAI OATS SgIMED plAM. 0* "1 2h TIME OF DEATH 26t PRONOUNCEO DEAD !W. OMI; n.) 210. PRONOUNCED DEAD Pwv) ril ti : SAL TO M bw W of Mw.wg1. NMw atewtM M SnM. W�PIi w10 Aw M 2K On M OMw d 11M4aW1n woor InvMSMlolt m aN oMMOn AM/I oeewna r /q 1w11MIMIlwi< �G / LNG / i-- $$ a M Mw wW ilwef ww AM 10 h ewwMlM MMMQ Sh Ob TOBACCO LNE CON7MUT[ TO M DEATW 70a HAS ORGAN CA TISSUE DONATION SEEN CONSIDERED? 700. WAS COMEEM ORANTEO? CI vim o No RUwoawN RTES o No a YES qf� SM. MAW AND VNYMCANl COMM EA'S PNYSIGLN OR COUNTY ATTORNEY) ffo. a Pees is ftt D fu x><�v A4c C'wa"'/ c 2ro c�it¢u� /Mr n .?6•Z0 • tiF G vz m 7SL DATE FRED SY FWM WAR AAA, Oft, W.) MAR