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<br />FROM :STAPLES FAX NO. :3083814636 Feb. 16 2004 09:45AMr P1
<br />200403641 n
<br />THE RAISED REAL OF THE NEBFRASX °R OMfA1• RECORD ON FILE WITH
<br />WHEN THIS COPY '
<br />SYSTEM, IT CERTIRES THE BELOW TO BE A' COPY O
<br />WHICH 1S
<br />THE NEBRASKA HEALTH ND UAiIA R SERVICES
<br />SYSTEM, VITAL STATISTICS SECTION,�r��
<br />THE LEGAL DEPOSITOR COOPER
<br />ANLEY S. COOPER
<br />DATE of ISSUANCE AsSisraNr srATE REGISTRAR
<br />JAN 10 2000 HEALTH AND HUMAN SERVICES SYSTEM
<br />LINCOLN, NEBRASKA OF HEALTH AND HUMAN g V10E5 PpdANCE AND StJppOAT
<br />STATE OF NLBRASIU DBPA1tT1+�1'R Y[iAL STAT MC9
<br />CERTIFICATE OF DEATH REk . —. 3. GATE 01 DEATH IMnnh DAy. lrtnrl
<br />— (IRBT . — MIC)IxE December 30 ! 1999 _ —., - --
<br />t, t1F.CEUI''.NT -NAME Rae Dunbar Female_
<br />Tammy � 1}ND£p , DAT A. Dn1'F. OF D1nTN rA1JnN+, Ddy YanN •' .
<br />yA, ACE L.ar B~'y U0.51 TZAR MINS 1965
<br />1 A,. ne'ml covM+'YI yp Alps D,tr$ 5C, HOUR9'
<br />A, CITY ANn RTATF.OF UIRTH Plno1N U.. ^• IY'.I � ^ _ — May?0! _._ - - -' --
<br />Grand Island, Nebraska_ •Y 8a PLACE OF DFAI
<br />y� Irbgr.nt QTftCn NureYgndmrt
<br />•, 9 9UCIAL. BECUMIY NUt40Et1 N_q""AL'
<br />❑ CR pytpanaM � Reednncc
<br />507 -98 -7442 Q ��
<br />in Aril •nAIUUAa,• pica er+nm a —•m numt+rl Prier ISPOC110 — . —. • —. - _.
<br />Ab. rar.ILITV Nnme A
<br />St. Francis Medical Center M INSIDE CIfVLWIY$ L. COUNTY or nF-ATk
<br />Bc. ,TV, TOW q U ?i�T1UNOF Vr•1TH ND r� Mall
<br />Yob L [l �n IN"IUF. GIIY 1.RdITS
<br />Grand Island — — CITY, TOWN QR LOCnTI IN 9d 5pTNCFT lNU HIIMBEH r +rrmtllnp7lp C aROI II
<br />qa. NCSIDENCE - STA ff DD. C'OUNTv 1817 W . 8th St. ! 68803 rds � No Ll
<br />Hall Grand Island _� -
<br />Nebraska 2 T__ "AARIEO O'J'JlDOWIFn to NAMFOF3POLSE Rt wlf 7/w mAN' nAm.l
<br />whwn. Blx• ArriM'I:rtn Inacn, ,+, ANCISTRY 1119 IlatAh, Alnlann, Gerrape. ek} Dal! 2 . Dunbar
<br />In RACK. Ia.O., IADOCMi NEvrR DIVOPL:FD
<br />ntc.l l:Lrcwy' White American - —
<br />t5 EDUCATION f9pncnY Onl�mOngat Qrnde cnmDlele0l
<br />Ian KINDOF BUSINESS S1 ay GONPQa n;�im "'I
<br />tin USUAL OCCUPATION r[:,�. t,nCa �+•t mane aw:np moot• ElsmAronry er 4oconey.ripl21
<br />nl TnrA+np AM, e'en it ronredl 1G MAInEry SURNnMC
<br />for Grou Service gpeciali t Prinicipal F ancial FIRST ",DDLk —
<br />Te. FATNEH —N .... FI 4 __.� MIT)OLE UST 17 MOTHER
<br />Seri
<br />" "L Penelope Lruth
<br />Leon Clarence McConnell - --
<br />IPA INfOftMANT -NAME
<br />tp, ,tiny f,FCEASISh F-vE. IN tJ.s. ARMFD --'---7 Dale Dunbar
<br />IrnA no. J• UnA,I (VI Tn9. true Par aw AAleb of 56—coal ' - - --
<br />No — — --
<br />„_—,—.. ISiPE @i 0� R 0.F,U NO" CITY OR TOwN Rl1TE. 24P}
<br />197 INFQRMANI MAlLINO ADDRE36
<br />1817 W. 8th St., Grand Island, NE. 68803
<br />_ .' �r�i':FMC7kH10P f:REMA10Rt NAME
<br />Er ACMFR - 61GNATUHE d LICENSE NU. �C � /� Dla NfrNQn aDrS ^OR'tKJN ' e,b. DATE
<br />/'//IJI �/ 7 ` Jan. 3, 2000�_West'lawn Memorial Park
<br />_ l .</v�•7 W N.ul°I RDmn..1 _ --
<br />-s td CFMS10" OR CREMATORY LOCATION C" Y OR TOWN 8
<br />A FUNERAI• ML - NAME Nebraska
<br />Anfpl- Butler- Geddes ❑ °'•""°' �°v "'" Grand Island, — •___�-- ._..._
<br />1123 West Second, Grand Island, NE 68801 _ --
<br />laormil ben.oan nnnnt and dAmr,
<br />7D. IMMEDIATE (,AI)RE _.- — IENtE4 ONLY ONE CAURE PEo UNF cOQ lac 1!4 ANQ Id} �, P���—
<br />PARTf , r
<br />I t Co.�c,er _� _
<br />P, � • Interval bdtWOen nnADl 1nC 0r.A11,
<br />e
<br />DUE TCJ, OR AS A CON "I 61 IFNCE OF
<br />DtJE TU. (A t AR A CONZF JLNU Or—
<br />II
<br />0 Ml 'u RIONIFICANT 17NDInON5 • Cmd Po,'r• nnnl}Irknhq In me Ant. DM riot MIMI PART III U' FFMAIJE. WAS THERE A 74 AUTOPRY 29 WAS CASC. nFFr:RRFD 10 MEDICAL
<br />PART - 010'(INANCY IN THE PAST 1 MOrJTN:i' EEnMINtN )A ,000ONFn7
<br />II 0"� -I- � N e t • fags. I0.5a1 Va.
<br />7RA -- ••. 26b TE -01� FQ j . (mr limy Yr.1 20': HOUR 0F IN•IUNT 2150 DII iCNIQE HOW INJUnT UCCVRRED
<br />t , l n�crdnnt ❑ Vnn.....rr „.,I..,I }D4A— �NJ_RI1Tt' M
<br />-...__
<br />❑ I.lu..... f. - I r.—m, Jon IN,unY AI WONF 2.I rLAC�OF TN.IURY - I Ipnp 'a•m, Pr..1 1>tt1Mr 360. COCATIUN STREET (,A A.C.D. NU. CI I T Q,1 TOWrI
<br />nlllce ,Mlr'g .I.: l�necMl
<br />❑
<br />U NO
<br />2aa, DATE Sw3NED (A/d. Uar rr r : ;n TIpAF. OF DEATH
<br />I
<br />2Ta. UPTC Or DfATH (AAA Day, v,.1
<br />�a-
<br />= �
<br />j(gpyi 6 <
<br />$
<br />_'
<br />Dud nATF. RIGNF.R /AM. Dry, rn
<br />111t,, TIME. OF OFATn
<br />``
<br />2BC. PRONOUNCED DEAD tA*a. (+n Y. yr,1
<br />2Dd. PRONOWyCrO RfAO lJ4A „!
<br />270, To The best of MY hoawlsdOe. death 00CWred the tVm Oetrt an6 D1 and due to the
<br />calleOlrl s101ea (�j(k
<br />S1 velure end Tub 'r'4L�±c..!_ V_
<br />780. On 1nq Daale Of etARxnAUOn .lnd'Or In.00Ypalbn. In my ODIrtIOn come OCCUIrnd AI
<br />the time. date and place and f1DO to Inc) dDU00I01 SIA100.
<br />. naN,a AM TON 10
<br />ase 29. DID TOBACCO USE CONTRIBUTE TO THE DF-ATHT
<br />0 res NU El UNKNOWN
<br />70,rt PAS ORGAN OR IISSUI A11ON MEN CON RED'
<br />rES E
<br />30,0 WAS CON$FNT ORAN .D'
<br />Yfi � NO
<br />31, NAME AND ADDRESS OF CERTIFIER fPHYSICIAN. COHONER'S PHYSICIAN ON COUNTY
<br />ATTORNFTI ITrM & MmJ ,. -•
<br />Kimberly A- Mickels M 729
<br />N Custer Ave., Grand Island, NE 6f3t103
<br />v nGr- .IoTRnR
<br />,..--
<br />axn DATE FILED By nF61RTRAn /Ab.. PAY. ».l
<br />JAN 7 2nnn
<br />
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