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� n �c � cr� c� uo � <br /> z y z � -T�t cn � a � o <br /> ^ m cr� � � � � c� Q. <br /> v� � = rn � � � rn � � <br /> '� o � <br /> �' o� o -^ � � <br /> � -,� ! �'`� '�"� z F--� �' <br /> � � � a �._`.. � n � o Z <br /> r� � � r- � � <br /> � �� ', r D � � <br /> � �'� � � � Z <br /> � ' `�' � v�D.. � O . <br /> � ' � • • �:_+ � � h-'' , <br /> N <br /> WF/EN TFpS COPY CARI�IES THE RA/SED SEAL OF THE NEBRASKA HEAL�llAl'¢Hl76UtAF�'I4f�ES � <br /> SYSTEII�IT CERTI�S TH�BELOW TO BE A TRUE COPY OF THE ORIQI�Ii�,=�llff�,€�tl � <br /> THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM,VITAL STi�IS�3 SEC�(,QN,WW.I�fi� <br /> THE LEOAL DEPOS/TORY FOR VITAL RECORDS - = - <br /> _ ) <br /> DATE OF 133UANCE �� <br /> _ N' ��. <br /> JAN � �998 9 9 10 8 8 41 - --- ��o,� <br /> ASS/�'AII�.S�Si�-�tEG/S�AR <br /> UNCOLN,NEBRASKA ' HEALTH A111D Hl�I7�S;EEiV�CE3�STL�M <br /> STATE OF NEBRASKA-DEPARTMENT OF HEAL'Pfd->'.-V=-✓ c <br /> BUREAU OF VITAL STATISTICS <br /> CERTIFICATE OF DEATH <br /> 1.DECEDENT-NAME FIFST MIDDLE � UST 2.SEX 3.DATE OF DEATH /AbnM.Day.Year/ <br /> 4.CITV AND STATE OF&RTH /Nnpf h U.S.A.nanr pounlry/ $e.AOE•Llsl BiMdey UNDER t VEAR UNDER 1 DAV 8.OATE OF BIRTH /Mpn1h,pay.Yser/ <br /> (Vn.l 5D.MOS. DAVS Se.HOURS' MINS. <br /> 89 ' ' , <br /> 7.SOCIAL SECURTIV NUMBER Ba PLACE OF DEATM <br /> � HOSPITAL: � Inpetienl OTHER: � Nunirg Home <br /> Bb.FACILITV-Narn� /pnd ms6RMion,Prvr sheN and numWr/ ' � ER�Oulps6ent � ReaMence , <br /> � <br /> ❑ �o� . �] o����,�., �tc; �l�are iTI11 <br /> &.pTY.TONM OR LOCATION OF DEATN 9d.INSIDE CITV LIMITS Be.COUNTV OF OEATN <br /> /� ... . _ . . Ya � � � <br /> 9a RESIDENCE-STATE � 9b.COUNTY 9t.CITV.TOWN LOCA ���� � gy.gTpE aM� <br /> /'�'���DZI��'oM/ - Ss:-NYSMfEF•1iY�LN.tI7S <br /> Vss� No� <br /> 10.MCE-(l.q.,WhiN.Blaek.Ameritan Mdian. 11.ANCESTRV�e.q..Msliin,ANRiCan,Oerman,ak� 1 . MARPoED ❑WIOpYVED 13.NAME1,O�F POUSE /N wde.giw m�iden name/ <br /> ek.IlSpscifyl ISOeefNl NEVER qVORCED RUtll <br /> 11s.USUALOCCUPATION /Oirolmdo/wcrfadorwWrigmoq 1�b.NINDOFBUSINESSINDUSTqV 15.EDUCATpN (SpseilyoNyhplNqpr compkpotl) <br /> d w�rkrg Mb,men il roA�rad) Ebmantary a Sseondary 10-72) � CoMege i�.a or 5�1 <br /> 16.FATHER•NAME FIRST MIOME UST 17.MOTMER FIRST MIDD�E MAID SURNAME <br /> 1UMT <br /> 18.WAS DECEASED EVER IN U.S.ARMED FORCES? 19a.INFORMANT-NAME <br /> Ives.ro.a unk.l („ris.Gve war W Cates d xrvicss) <br /> 19C INFORMANT MAILING AppRFSS ISTREET OR R.F D.NO..C WN.STATE.ZIPI <br /> 20.EMBALMEF-SIGNATURE d IICENSE NO. 21 a.METMOD OF dSPOSITION 21b.DATE � 21a CEME7ERY OR CREMATORV-NAME <br /> �Bwial �Removal �Ce <br /> 22a FUNERAL MOME-NAME 27d.CEMETERV OR REMA70RY LOCATiON CiTV OR TpNM STATE <br /> Kleine Funeral Home �°'°""°°" �°onatroi <br /> 22b.FUNERAL HOME ADDRESS (STREET OR R.F.D.NO..GTV OR TOWN.STATE,ZIP� - <br /> 23. IMMEDUTE CAUSE (EN E E F al� . q I Imerval beiween onse�and eeatn <br /> PAR7 � �O <br /> � a <br /> � lal X 1fl1 � <br /> DUE TO. AS A CONSEOUENCE OF' I Intanai Oetwesn a�set arW tleaU <br /> ,b, P��,� �P���,a.�., �.�s� � ; 3�� <br /> -- �T^,.OF�A,;,;AF;SECUENC�C`F- __ . _ _ I Interval belween onset antl oeatn <br /> I <br /> (�) � <br /> I <br /> OTMER SIGNIFICANT CONDITpNS-Ca�dipons conViDuErp b the deaM bul nol rslatetl PART III IF FEMALE.WAS THERE A 2a.AUTOPSV 25.W�5 CnSE REFERiiED TO MEDICAL <br /> PART PFEGNANCV M THE PAST 3 MONTHS? EXAMINER OR CORONER9 <br /> ° c RO u �9 <br /> IAges�0-54) Yes No Yea No Yes No <br /> 26a. � .DATE MIJURV /MO..Dey.Yr.J 26c.HOVR pF INJURV 28d.DESCRIBE HOW INJURV OCCURRED <br /> � AccMeM � UMelerrtnneA - <br /> M <br /> � SuiciOe � Pentlirg 28e.INJURV AT WORN 261.PU�CE OF�JU�HY��hoD�g,larm,sireet.lacbry 26g.LOCATION STREET OR R.F.D.NO. CITV pR TOWN STATE <br /> � ❑ olfic 6uild ny� <br /> � HortMCiAe krvesu9a�^ Vea No � <br /> 27a.DA7E OF DEATH /MO..Day Vr� 28a.DATE SIGNED (MO.Day.Ycl 28b.TIME OF DEATH <br /> � �t'��� a�� M <br /> �� 27b.DATE SIGNED /Ma.Dey.Ycl 27a TIME OF DEATH � �`� 2Be.PqONOUNCED DEAD /MO.Day,Ycl 28d.PRONOUNCED DEAD /HOUrI <br /> �� ', c�a �� <br /> 8� �"� g M <br /> 27E.To bM d my knowbOge.tlaath ocCwretl at me, and s and dua b Me .°.�� 288.pn Mg pegig d eKiminalion and�or inveslgetqn,in my opmon Aealh occurce0 at <br /> causa�sl s�a1sA. c� a the time.dale arW psce and aue ro tne causels�steteE. <br /> � �S�neMS�rW Tips �nalure antl 7iqe <br /> I29.DID TOBACCO USE CONTRIBUT ME TH? 3Qa MAS OfiGAN OR TISSUE DONATION BEEN CON ERED? 30.b WAS CONSENT GRANTED? <br /> � VES�1� NO � UNKNOWN � VES NO � VES NO <br /> 31.NAME AND ADDiiESS OF CERTIFIEA(PHVSICIAN,CORONER'S PHVSICpN OR COUNTV ATTORNEV) lTypBaPnnp <br /> Kimber 72 <br /> 32a.REGISTRAR 1, 32b.DATE FILED BV REG�STRAR /MO.,Day.Yr) <br /> �! OV 1997 <br /> Lot Twenty (2p) , Block One ( 1) , Continental Garden� _ �„ naa: �� __ <br /> c; t<, ,.F ..--- , _ _ _ . . , �. <br />