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� � <br /> �� � �" 2 � � �� � �- <br /> � � � D '-= n = � � -�•"! � o <br /> � n "� p � � � r-�- --1 � Ca sz <br /> 5 �N � � � N m � � N <br /> l,-� � o O0 'h y"� }-+ � <br /> -*t <br /> � � �'� r.� � � � W � � <br /> � � � m � � � � � <br /> C'1 <br /> °�.9 ,�.� � �, �, � r �� °� � <br /> o � "'s' � � ^' "```. � o <br /> N � �' � <br /> , <br /> � <br /> � RECORDER'S M�l�tO: Lot 15, Slock 2, Southern Acres Addition �� <br /> p To City of Graad Island, Hall County, NE � o <br /> 99 �07617 _ . . <br /> WHEN TF�S COPY CA/�3 Tf�RAISED SEAL OF THE NEBRASKA HEALTH AND HlL�ifA��ES <br /> SYSTEIY�IT CERT�ES Ti�E BELOW TO BE A TRUE COPY OF THE OR/OINAL RE�Q�€l�i_ <br /> THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM,VITAL STAT/STIC��E�F�E�11L_W1�fi-��� <br /> THE LEf3AL DEPOS/TORYFOR VITAL RECORDS. �-_-; _. `� `� <br /> DATE OF/SSUANCE - ��-" ` <br /> ±-1s�t,:_- _ _ _ - <br /> -4 w��s:�,� _.� <br /> = <br /> NIAR_ 1 2 1999 ass�s��r,�tr��oasr�� :�. <br /> LINCOLN,NEBRASKA HEALTH AND HUNfAN SER4i9(�3.&1�S}1EM�� <br /> ' STATE OF NEBRASKA-DEPARTMEN'f OF HSALTH AND HUMAN SER1Ji�S�T1Ri'7C�/4iq�:SUPELiRT <br /> V17'AL STATLS'fIC3 <br /> CERTIFICATE OF DEATH v --_-- _= 9 H �O S 6 <br /> 1.DECEOENT•NAME FIRST MIDOLE ' UST 2.SEX 3.DATE OF DEATH lManM.DaY.YNrI <br /> Morris Melvin Kauk Male Se tember 25 1998 <br /> �.CITV AND S7ATE OF&RTN /Nnofh U.SA.n�nw ca�wMy/ Sa.AGE•LW BiNWay UNDER 1 VEAR UNDER t DAV 8.OATE OF BIRTN /Mp�OR Day.Ysar/ <br /> Saronvil le, Nebraska (Yn'' 75 �° Mos � ��S x.�,RS� M�NS. November 5 1922 <br /> . 7.SOCLLL SECURTIV NUMBER 8a PUCE OF DEATH <br /> • 506�20-�071 HOSPITAL: � Inpebenl OTHER: � Nuroingfbme <br /> !0.FACIUTV-N�mO . lMnd ruMWa�.DIH sMSf Iml mxnW/1 O ER Ou�MilM � iMsiCente <br /> , Residence-2610 Brahma Street � DOA ❑ 01hsr,�,", <br /> EC.CITV.TpWN OR LOCATqN OF DEATH Bd.iNSIDE CITV L1MRS Be.COUNTV OF DEATH <br /> Grand Island, Neb:raska �N � � ❑ Hall <br /> 9a RESIDENCE•BTATE 9b.COUNTV 9c.CITV.TOWN OR LOCA710N Cd.SIREET AND NUMBER /MCNdlnp2'p Co0s1 9e.INSIDE CITV UMITS <br /> Nebraska Hal l Grand Isl and 2610 Brahma Street YN� �❑ <br /> f 0.MCE-'NA-WMM.Bycl'.Mrriean Indan. 11.ANCES7RY Is.p..NM4n.1YNxican.f3�rmm,Nc) �.!'1 t 2..�MARPoEO ❑WIDOWED /3.NAME OF SPOUSE /a wile.pirr miiaen n�msl <br /> V <br /> �II�) White (��) German NEVER qVORCEO Helen Trautman <br /> tk USUAL OCCUPATION /fL'N M�d W ront ab�w aWMp maf �I/� 1 r0.KIND OF BUSINESS INDUSTRV O1� 15.EWCATpN (Sp�cily mM -hu1 paAS canple40) <br /> Wwak'wgNknw�NnWr01 � I J ENmaM�ryuSscorWery 10-t21 ' Cdkqe It-aor5�1 <br /> � tE.FATMER•NAME fHST MIODLE UST 17.MOTHER FIRST MIDDLE MAIDEN SURNAME <br /> (dec) Ben'amin Kauk dec Ella Rauscher <br /> ' 1!.WAS DECEASED EVER IN U.S.ARMED FORCES? 1Da.INFORMANT•NAME <br /> IYa.ro.a wMcl Ip yn.qiw wu and d�d Nrvkal <br /> Helen Kauk <br /> 19b.INfORMANT MAILIN(;ADDRESS ISTHEET OR R.F.D.NO..CtTV OH TOWN.STATE.ZIPI <br /> 2610 Brahma Street Grand Island, NE 68801 <br /> Z0.EMBALMER•910NATURE 8 LICENSE NO. /�O[�J 2f s.METMOD OF pSPOSITiON 21b.DATE 21c.CEMETEFV OR CREMATORV�NAME <br /> t5 Z/ <br /> �� ❑��a� Se t. 29 1998 Westlawn Mem ri ark <br /> 22a UNEML FIOME-NAM ' � 210. EMETERY OFi CREMATORY LOCATION C17v OR TOWN STA7E <br /> Jacobsen Funeral Home ❑�^ ❑°°^°��^ Grand Island, Nebraska <br /> Y2E.FUNEHAL IIOME ADDRESS (STREET OR R.F D.NO..CITV OR TOWN.STATE,ZIP) <br /> 411 "0" Street St. Paul , NE 68873 <br /> 23. IMMEDMTE CAUSE IENTER ONLY ONE CAUSE PER LINE FOR lal.10�.AND�cp � �rnsrvai betwesn onae�and eeam <br /> PART w lr � r <br /> �� �'v` � f �` � <br /> I <br /> lil � <br /> � DUE T0.OR AS A CONSEOUENCE OF: � I Im�rvai bsn+een onset aM tleaM <br /> i <br /> roi � <br /> WE TO,OR AS A CONSEOUENCE OF� I IMSrvN bMween oneet aM OeaM <br /> i <br /> i <br /> IN � <br /> OTHER SqNIFICANT CONDfT10NS-Ca'Wilions conMbitlrp q tl�e OeaM Dul raf rNa1aE PAHT 11�IF FEMALE.WAS THERE A 2�.AUTOPSV 25.WAS CASE REFERRED TO MEDICAI <br /> PART PqEGNANCY IN THE PAST 3 MONTHS4 E%AMINER OR CORONER? <br /> N <br /> (Ages�O-Sq Vp No Vsa No Ves No <br /> Pga. 26b.DATE OF INJURV (MO..D�y.Vr.) 28c.HOUF OF INJURY 28E.DESCRIBE HOW MUURV OCCURRED <br /> ❑ Atcidsnl ❑ UndsMminstl M <br /> � S�rCids � P�rWinq 26s.IWURV AT WOpK 28f.PUa E(�F,I�NdU�HY`L�t ,. .la�m.s�reet.lae6wy 26q.LOCATION STREET OF R.F.D.NO. CI7v OR TOWN STA7E <br /> o1G bu � <br /> � HOrtMtide ImNSeqe6on Vq� No� <br /> 27a DATE OF DEATH (Ma.D�y.Yr.J n 28a.DATE SI(3NED /Ma.Oay.Yrl 28b.7IME OP DEATH <br /> a r ���I � a M <br /> �y 27b.DATE SqNED IM0..D�y.Yr 27c.TIME OF DEATH ��Y 28t.PiiONOUNCED DEAD (MO..Wy,Yil 280.PRONOUNCED DEAD /Fbu�l <br /> � � • �- j� � . O � M ��`� <br /> 8 M <br /> °� 27A.To Ih�W�t d my knowNJpe. aM eurrsd a IM tlrtia ar�/ b ths �� 28e.On�ha buis d sKaminatbn antl�a imsstpadon.in my opinbn Ceatn occurreC at <br /> cawNy�ayyd 1, // �, � Ihe 6me.deb uW plaes antl due ro tla esuse�sl ra�eE. <br /> .�a rms �i W Ti11B <br /> 2�.DID TOBACCO USE CONTPoBUTE TO HE DEATH? 30.a HAS OH6AN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? <br /> � YES W NO � UNKNOWN � VES � NO � VES �NO <br /> /`� f . <br /> 31.tj�lA�AN�A�OF�[RTIFIER IP}IVSICIAN.CONONER'S PH7$ICI�N�CQUNTY�NEVI_lTy��Pnnl/�� <br /> �a 61f/Y i:i�jN G��b�i'/��,d w��� <br /> 32a 61S 32b.DATE FILED BV REGISTRAR /Mo..O�y.Yc/ <br /> ._.�. - n�T 91� <br />