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/ <br /> a �^MEN THIS COPY CARRIES THE RAISED SEAL OF TIiE NEBRASKA HEALTH AND HUMAN SERVICES � <br /> ';YSTEIY�!f CERTIFIES TFlE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOI7D ON F1LE WITH <br /> 7HE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM,VlTAL STATISTlCS S�C170N,NM1CH IS <br /> THE LEGAL DEPOSlTORY FOR VITAL RECORDS. � /J _ <br /> I1fdAG� <br /> �A���111999 � . AN�s.coo�a 9 9 10 9 5 9"� <br /> ASSISTANT STATE REG/STRAR <br /> UNCOLN.NEBRASKA HEALTH AND NUMAI�I SERNICES SYSTEM <br /> ' STA7E OF NEBRASKA-DEPAR7I�NI'Of}ff.AL7H AND HIJMAN SERVICES FlNANCE AND 9UPPORT <br /> VTfAL STATIS77CS � <br /> CERTIFICA'TE OF DEATH <br /> 1 DECEOENT-NAME FtRST ' MIDDLE L�ST 2 SE% 7 DATE OF OFhTH /Mwam.Dar yw�l <br /> Vernon Haun Male December 25 1998 <br /> �.ChV�FD JTA7E DF BIRTH I/rof n USA..nsms cOU�by1 5�.AGE-LaM&�1MaY ��R t VEAR UNDER 1 DAV !.OATE OF&RtH IMar�h.D�Y YM�) . <br /> ",�, 97 � M°S � a�s x�"�; �"S December 20 1901 <br /> Sioux Cit Iowa <br /> 7 $OCIAL SECUATIV NUMBEA Ba.PLACE OF DFJ1iH <br /> � MOSPfTAI'. � M� �T�p� � ���'� � <br /> � 507-24-4874 � ERppiWrM ❑ �• <br /> so ��auir-N�me Mnawrrtuhm.W�+arosrwnu�DM <br /> ❑ ppA � OMr(SWMI'� <br /> • PARK PLACE NURSING HOME � �NS�o��iTruMirs Ba GOUNTYOFDEATH <br /> 6c C�fv 70WN OR IOGAT1pN OF DEATM <br /> GRAND ISLAND r.. � ►w ❑ HALL <br /> 9a RESiDENCE-STATE BD COUM7Y <br /> 9c.C�YY.TOWN Oii LOCAip�+ 9E.STREET ANO NUMBER A�cN,airp20��1 4e n+SiDE C17v L�urtS <br /> NEBRASKA HALL GRAND ISLAND ��`� �❑ <br /> 10 RACE-la.p..NRNe.&Kk.Amer�an Mi�n. 11.ANCESiRY Is.g..lU►en.Me.K�n.(;srtnsn,elcl �2.�MARPoED ❑VYIDOWED 13 NAME OF SVOUSE /M wde.D^+�"ab^^�^bl <br /> .,�,,�,�, (SW�MI NEVEH pvORCED ALL �[GE$-- <br /> WHITE GERMAN <br /> �N USUAL OCCUP�TION lGne kiMd�O+k ab+»A�+i'p mas� 1�E KIND OF BUSINESS INDUSiRY �s.EDUC�TION (SP���Y�Y 9����e1°�� <br /> d�o+kmgA+b.nenNnMMI E4mMUryaSsemGry10��2� ' Cdk9�1�.�a5•i <br /> BRAKEMAN CONDUCTOR UNION PACIFIC RAILROA mu <br /> �6.FAiMER•NAME FINST MIDD�E USt 17.MOTNER fIRST MIDDLE MWDEN SUHNAME <br /> DAN A <br /> t8 WAS DECEASED EVER IN U.5 MMED FORCES? 19a.MFpRMANT-NAME <br /> IYes�o a unk.) in xs.a�.a��ro a.ies a,e�ncal <br /> i1Tnw�P�t+ V T fiw� <br /> 19b INFpRMANT MAIUNG ADDi7ES5 ISTREET Oil R F.D.NO..CT'OR TOWN.STATE.2IPI <br /> 2p EM' ER- IG ATUHE6l ENS NO. 21a METHODOFDiSPOSirpN P1D.D�7E 21c CEMETERYOfiCREMATORY-NAME <br /> - Z �eu;.� ❑�•� 12-28-98 FULLERTON CEMETERY <br /> 4a F ME� M 210 CEMETERV OR CAEMATORY�OCATION C�TY OR TOWN S1ATE <br /> PALMER FUNERAL HOMES INC. �`'°"� �°o"'�'� FULLERTON NEBRASKA <br /> 22o FUNERAL iqME ADOAESS ISTREEi OR R.F.D.NO..CITV OR TOWN.STATE.ZIPI <br /> 21 0 IRVING P.O. BOX 332 FULLERTON NEBRASKA 68638-03 2- I ��a���aMaes� <br /> 23 IMMED�ATE CAUSE (ENTER ONLY ONE CAUSE PEA UNE FOA�si Ib1.AND Icll � <br /> P�R1 � <br /> � Congestive heart failure. � — <br /> 1�1 � Mnvai Dehreen onui ana Oeam . <br /> � WE TO.OR AS�CONSEWENCE OF . I <br /> 1 <br /> . � <br /> roi <br /> 1 Merval pe�ween on�aM aean <br /> DUE TO.OR AS A CONSEOUENCE OF� 1 <br /> I • <br /> Itl .` 1 <br /> OTHER SKaNIFIC�NT CONOITIONS-Cod�Mn��q b E+e OeaT Out nd roUbC pqEGNANCY IN THE AST]EMONTMS �• ���Sr � E%AANNEA OA COAONE�MEpCµ <br /> P�RT <br /> p (Aqes 10-S�I Ves No Yes No Yss No <br /> � 26D DATE OF MJUNV /Ab..D�y Yr.l 26c.MOUR OF MIJURV Z60.OESCAIBE HOW�NJURY pCCUPREO . <br /> � AccieeM � UMMermw�W M <br /> � $u¢We � Ps'M��g 26a.NUURV AT WORN 261.PUe�a.��V� N�o?w.la�m.s�reei.l�cby 26q IOC��ON STREET OR A.F.D.NO. CITV OR TOWN ST�TE <br /> o�¢ /SOCC�I'1 <br /> � rbrmeds tives�gauan y�y� �� <br /> 27� DATE OF DEATH fMp WY.Yt) 2Ba.DRTE S�GNED /Ab.OI�Y Yrl 2!C TIME OF DEATM <br /> a5 12-25-1998 a�� M <br /> �, P�.DATE SIGNED /Ab_Ory Yrl 27c THAE OF DEATM t 2Ec.PRONWNCEO DEAD IMo.Ory.Yr./ 2EC.PRONWNCED DEAD Mowi <br /> ��yg� 01-04-1999 09:OOAM M ���� M <br /> � x t a tims.Wk�na d e aM due b Mie 2!e O�+he Dais d�umrnron�nE•a inss6p+lion.n mY op^a^Ceam xcwrsE a� <br /> 270 7o tne Dest d^7 k^��� ��e Ina eme.Csb�nE d+�e xid Oue o 1M uusela�t4NA <br /> � uusNsl s�arod. <br /> IS nalur�arW TNb► ud ii1N <br /> 29 D�0 TOBACCO USE CONTRIBU TO 0 . �Oa F1A5ORGAN OF1 TiSSUE DOnATqN BEEN OrrS�DEaEO� JOD W�S CONSENt Gw�NTED� <br /> � rE5 �+O u�+RNOwN . � rES �� ❑ �S N� <br /> 71.NAME AND ADORESS OF CEATIFIFA IPHVSICIAN,COf10NER5�HYSICNN OF COUNN ATTORHE�I (�VOS�'�1 <br /> William J. Lawton M.D. P.O. Box 50 Grand Island, NE 68802 <br /> J2� pEGIStRAR �2U DATE F�LEO B�PFfi1�5?MR (MO �/f��(fA <br /> J��N �, 1JJJ <br /> . <br /> i <br />