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A � c.n c� cn o '.� <br /> � C a b � cr' z � o �' <br /> .< = b 2 n = � � � –i m cD �o. <br /> m N N � � r N p � � � <br /> � 7�C = ���' C7� "*1 -"" <br /> S -n Z F--� � <br /> � fTS ,r,.'�.y � D � O ;�+ <br /> �i � r � � � <br /> o �,p r v 3 <br /> � � �' `�' � �` � 3 <br /> � �� n � � <br /> c.J �� Z <br /> � � �, o 0 <br /> � <br /> WHEN THlS COPY CARR/ES THE RA/SED SEAL OF THE NEBRASKA STATE DEl����LT� � <br /> ?CERT/f/ES THE BELOW TO BE A TRUE COPY Of AN OR/Q/NAL RECORD ON!!EF Y1��1 THE�#'/[7'E � <br /> DEPARTMENT Of HEALTH,BUREAU Of V?AL STAT/ST/CS, WH/CH/S THE L��f,P_$$1�-0RY-f�, <br /> V?AL RECOROS. _ -_ ,�-- _ <br /> DATEOF/SSUANCE gg�-4������� _ ���,� <br /> �_.',!0`-" = <br /> DEC 2 8 1995 =: sr- �. &°'`�� <br /> ASSlSF�T S ,_T6 REBlS�RAR <br /> L/NCOLN,NESRASKA NEBRASKA DEA4RT��Jf�IEALTfI <br /> 4 STATE OF NEBRASKA-DEPARTMENT OF HEALTFI _- -- <br /> BUREAU OF VITAL STATISTICS --_ <br /> CERTIFICATE OF DEATH <br /> 7 DECEDENT�NAME FIRST M�DDLE 1A5T 2 SEX ��3 DATE OF},_pTH iMOn��Dav Yearl <br /> I <br /> Vera Ma <br /> 4 CITV AND STATE OF B�RTH lllnotn USA.name counhy; 5a AGE-last&rttWay UNDER t YEAR UNDER�DAV 6.DATE CF BIRTH �Monpr.Day.YearJ <br /> (YrSI 5p MOS � DAVS 5[.FIOURS MINS <br /> Archer Nebraska ' <br /> 7.SOCIAL SECURTIV NUM6ER Ba.PUCE OF DEATH <br /> MOSPRAL Inpa6erit OTHEfi hu.sirg Home <br /> � 507-38-7044 --- — ❑ <br /> BG FApUTV-Neme /Nnd rnSliN(Im.grro Slieel aM numOn�J � ER pu�aEerh Aence <br /> • 105 rn r L � °OA �����"� <br /> & CITY TONM OR LOCATION OF DEATH 8tl INSIDE CITV LIMITS Be COUNTV pF pEpTH <br /> Cairo �� ^� ❑ , , <br /> 98 AES�DENCE-STATE 9E COUNTV 9C CITV.TOWN OR LOCATION 9G STREET AND NUMBER /MnuongZp Cotlel 9e INSIDE C�TV LIMITS� <br /> Nebrask • �as �� <br /> 10 RACE-le.q..WMN Black.Amarwm Y+dan. 11.ANCESTRV le.g MWn.MeMican.Ga,man.e�cl �2.�MARRIED ❑WIDOWED t3 NAME OF SPOUSE lll wAe.9rve mapen namg) <br /> ele.IiSOecAyl ISDeCAYI L��� <br /> W NEVER DIVORCED <br /> 1 H USUAL OCCUPATION /Grve kxqd work done du�ng mos! 14D KIND OF BUSINESS INDUSTRV 15 EDUCATION �SpecW only hghest gratle complate0) <br /> d■orkrngGAr.�nAreMed/ ElememaryaSacoroaryl0-t21 Cdlegel�.aor�,•i <br /> H <br /> 16.FATHER-NAME FIRST MIODLE U5T 17 MOTNER FIRST MIODLE MAIDEN SURNAME <br /> 18 WAS DECEASED EVER IN US.AHMED FORCE . 79a.MFO ANT-NAME � <br /> (Ves.no.a unkl IM yes give war antl Aa�es d xrvKesl � <br /> 19p INFORMANT MAILMIG AOORESS fSTREET OR RFD NO..CRV OR TOWN.STATE.ZIPI I/ <br /> 1 <br /> 20.EMBAIMEq-SIGNATURE 6 LICE NO. � 21a METIp00F DISPpSITqN 21b.DATE 21c CEMETERY OR CREMATOA� NAME d, <br /> �� �b ` � � .�rW �Removai � <br /> 72a FUNERAL NAME 21tl.CEM ERV CREMA LOCATtON • � <br /> ❑� ❑� <br /> _s ; <br /> � <br /> 22E.FU RAL FIOME ADDRESS ISTREET OR R P.O.NO..qTY OR TOWN.STATE.ZIP� O <br /> 23. IMMEDIATE CAUSE (EN7ER ONIY ONE CAUSE PER LME FOR lal.Ib�.AND�cll i Inlerval belween pnset ano tleam � <br /> P'�e HEMORRHAGE AT LARENGECTOMY SITE � UNKNOWN <br /> � <br /> � DUE TO,OR AS A CONSEWENCE OF � Imervai be�ween onset ara oeatn / , <br /> je' � L <br /> DUE TO.OR AS A CONSEOUENCE OF� i `' � <br /> r - � Interval Oelween onsei anU ceam `J <br /> ��� THROAT CANCER , � _ <br /> OTHER SIGNIFICANT CONOITIONS-CanOnrons coMriGAng ro Ihe Oeam Dul not relatetl PAR7 lil IF FEMALE WAS THERE A '��2a AUTOPS� 25.WAS CASE REFERRED TO MEDICAL �' <br /> P�RT � PREGNANCY IN THE PAST 3 MONiHS� EXAMMER OR CORONER� � J <br /> H � <br /> �Aqes 10-54� Ye5 No Yes 4: Vqs p�p �. <br /> 26a. 26D.DA7E OF IWUHY /Mp..Day,YcJ 26[ HpUp pF INJUFV Z6C.DESCR18E FpW INJURV OCCURRED r S <br /> � AccMeM � UrMalemmne0 M � � <br /> � $u¢iAe � Pentlirg 28e.INJURV AT WORK 26f PUC����V;{U Iqrtie�.larm.street.facbry 26g.LOCATION STREET OR R.F D NJ Ci7Y OR TOWN STATE O� � <br /> � olhce SOxsY � <br /> o ��, ,�� ��❑ �❑ , <br /> 27a DATE OF DEATH lAb..OaY Y��1 2Ba.DATE SIGNED /Ab..Dar ��% 2BD TIME OF DEATH , � <br /> _ �yQ a7—o7�' �,j 10:35 a. M U � <br /> �`� 27C DATE SIGNED /MO..Day.YU 27c TIME OF DEATM �6`� 2& PRONWNCEO DEAD /A1c Day.V!! 28tl.PRONOUNCED DEAD (Fbun . � � <br /> 8�� M �a�� 12-6-95 � 11:05 a. M - <br /> g=� � ; <br /> 270 T o Ihe besl ol my knowletl9e.tleath occuneC at 1he Ume.aaM arW d�e ana tlue a t1�e �o 0 2Be.On the bays d examinatwn aM a n in m urr at <br /> � <br /> �.�5�� �n�.�a�w� a �:�5, �, y°Ff C. FINECY 'O <br /> I anxe antl Title &nawre xM TIMe � S•• <br /> 29 pD T08ACCp USE CONTRIBUTE TO THE DEATM� 3p.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED� I 30D WAS COMSENT GRANTED �J <br /> L <br /> � YES � NO � UNKNOWN � VES � NO � VES � NO � <br /> 31.NAME AND ADDRESS OF CERTIFIEF(�VSICIAN,CORONER�S PNVSICUIN OR COUNTY ATTORNEV� /rype cr Pnnry � <br /> DEPUTY CLARK FINECY, HALL COUNTY SHERIFF"S DEPT. , GRAND ISLAND, NE 68801 � � <br /> 3?a REGISTINR 37D.DATE FILEpBY AfGIGTWW �Nb..qy.Yr/ � <br /> �.. <br /> , .. � .��..... ,. ,�'� , �. . ,.. . ... . ... -, , � .. <br />