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m n n <br /> /�t m tan <br /> � ° O n a p � c� o -�i Q <br /> �� � � � = N � � c a rn <br /> :_;, o � <br /> � \I �r �-�- '� r�,,, ��, --� � o � o <br /> T� � � `�` -r� � G. <br /> �` '� _ c��" '°%� p �' F-� N <br /> � � `� � `� �"� Tr C�7 O <br /> G � `�P � r" � =.� � ,��. �° �' <br /> �' S � vi r--+ u� � C <br /> �� � .�.�D... ~ � <br /> • - �.; � � � � <br /> 99 i09gi3 � <br /> � <br /> WHEN THIS COPY CAF�FtIE31}E RAISED 3EAL OF THE NEBRASKA HEALTH AND HUMAN SER1//CES <br /> SYSTEII�IT CERTAFES TFE BELOW TO BE A TRUE COPY OF THE ORIOINAL� ,�� WITIi <br /> THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEIY�VITAL STA � �CH IS <br /> THE LEOAL DEPOSITORY FOR VITAL RECORDS -- �`�_ '�_ - � <br /> �Q <br /> DATE OF 133UANCE • ��� \ <br /> SEP 7 1999 ==" _ ��R <br /> ,��,�iir� - - - <br /> uNCO�.►w n�eRasKa . -- rrea�n�,u��N s�s�� <br /> STATE OF NEHRASKA-DEPARTMENf OF F�AL'!H AND HUMAN�tI,ES I3N�SUPPORT <br /> V1TAL STA77STICS -_ � '- <br /> CERTIFICATE OF DEATH � <br /> 1.OECEDENT-NAME FIRST MIDDLE UST 2.SE% 3.DATE OF DEATH /MOnM.Day YeerJ <br /> Golda Irene <br /> a.CI7V AND STATE OF BIRTH /Hnot ir UBA..neme cpmpyl Ss.AGE-L,aat&NMay UNDER 1 VEAR UNDER 1 DAV 6.DATE F BIRTH./MOnOh.Day.Yeai/ <br /> �r�o.l Sb.MOS. ' DAVS Se.HpURS' MINS. <br /> Cla Count , Nebraska _No <br /> - 7.SOCIALSECURTIVNUMBER 506-30-6986 ��PUCEOFDEATH �-1 <br /> � ,. . .... .�, HOS.�PI�TAL: , �J.UWetisM OTHEF: � Nuraing Home <br /> Bb.FApLITV-Name /Hnof insHMipn,give slreer and number/ ' -�� ER O�tlpatieM � Resitlence <br /> . <br /> Bryan LGH Medical Center East � °OA ❑ 01������� <br /> 8c.qTV.TOWN OR LOCATION OF DEATH ` 8d.INSIDE CITY Lµ1RS Be.CIXNITV OF DEATH <br /> Lincoln '- �°° nx "°,❑ Lancas e <br /> 9a.RESIDENCE-STATE 90.COUNTY � 9t,CITV.TONM OR LOCATION Bd.STHEET AND NUMBER /Inc/udiny Zip Code/ 9e.INSIDE GTV LIMITS <br /> Nebraska Hall Grand Island 209 W. 21 St. 68801 ���C] No❑ <br /> 10.RACE-(e.g..Whde.Black.American NOian. 11.ANCESTRV Ie.g..lUli�n.Maxican.Gwm�n,NCI 12.�MARPoED O WIDOWED 13.NAME OF SPOUSE ltl wde.grve maiden nams/ <br /> �8 "s��tyl (�C�� C � NEVER DIVORCED Robert Nutzman <br /> .lte American <br /> 14a.USUAL OCCUPATION /Grve kind d rvrk dons duiig masf 1�E.KIND OF BUSINESS INDUSTRY 15.EDUCATION �Specily ony hghest qrWe compbted� <br /> dxwkiig/ile.e`9nAreliretll EbmenlvypSecontlaryl0-12) .� CoMegq.�t-dor5�l <br /> Bookkee in Bookkee r ll � <br /> 16.FATHER-NAME FIRST MIDDLE � I.AST 17.MOTHER FIRST MIDDLE MAIDEN SURNAME <br /> George Gerdes Clara Smith <br /> 18.WAS DECEASED EVERIN US.AHMED FOqCES? 19a INFORMANT-NAME � <br /> �Yes.ra.w unk.) pl yes.grve war an0 tlates ol aerviees� <br /> No Robert Nutzman <br /> igp.INfORMANT MAILING ADDRESS ISTREET OR R.F.D.NO.,CITV OR TOWN.STATE.ZIP� <br /> 209 West 21 St. Grand Island, Nebraska 68801 <br /> Z0.E LMER-SIGN URE 6 LICE E N /O�� 21 a.METliOp pF pISPp$ITqN 21b.DATE 2�c.CEME7ERV OR CREMATORV�NAME <br /> [��� ❑�,e� 8-24-1999 Grand Island Cemetery <br /> 22a FUNEqAL HOME-NAM 21d.CEMETERY OR CREMATOAV LOCATION qTV OR TOWN STATE <br /> A fel-B G"�°°" �°on"'°" Grand Island, �Nebraska ' <br /> Y2b. UNERAL HOME ADDRESS (STREET Oq RF.D.NO..CITV Ofi TOWN.STATE,ZIP� <br /> 1123 W. 2nd St. Grand Island Nebraska 6 <br /> 23. IMMEDIATE CAUSE �EN7ER ONLV E CAUSE PER UNE f0ii la�.(b�,AND�q) 1 Irnerval behveee onset and dealn <br /> PART �/ <br /> � I (e�^ �� � r,`,L ���� <br /> � OUE TO,OR AS A SEWENCE OF� . I knerval pelween one9t a tleaM <br /> •s � i <br /> 1 Ibl � <br /> i <br /> DUE TO.OR AS A CONSE01fEIVC� . " � - i �mervai between onse�and aeatn <br /> i <br /> X � <br /> i" � <br /> P'RT OTHER SkyJIF1CANTQCONCITJO�S`-^ M `a(WiEW�np M�`=bu1 nd� pqEGNANCV IAN THE PAST 3EMpNTH ? zd AUTOPSV Z5.E AM�INER OR CORONEq MEOICAL <br /> �(-il �y �r a r►•� c.4� x <br /> � � <br /> (Age510-5q V8s No Ves No Ves No <br /> Na. 26D. E OF INJURV /MO..Oay.Yr./ Z6c.Hq1R OF INJUAY 26d.DESCPoBE HOW INJURV U D <br /> � AccitleM � Untle�ermineC M <br /> � Suicide � PerWing 26e.iNJURV AT WORK 26f.PUe E INJeUURV% t�lqtrs,qrm,saeet.faebry 26g.LOCqTION STFEET OF 0.F.D.N0. GTV OR TOWN STA7E <br /> ❑ ❑ df bui M/ <br /> � NomiciAe ��nvesGgation y� � � <br /> 27a.DA7E OF DEATH /Mp.pay.Yr.) 28y.DATE SIGNED /Ab..Day.Yr.l 28b.TIME OF DEATH <br /> a< � ou� �"1 -1 a M <br /> �� 27b.DATE SIGNED ..Day.YrJ 27c.TMAE OF DEATM ��� 29C,p{pNpUNCED DEAO lAb..Day,Yr/ 2&f.PROMOUNCED DEAD /Hqir) <br /> �� � '.` vCL �lJ0 M "`� M <br /> �� 27d.7o the besl d my k xcurrotl at hs fims anE plKe aM due b ps �� 2Bs.pn pb puie d eKaminauon and.�a irvssugation,in my opn�on CeaM ocwned a� <br /> tause�sl s�a�ed. � c�a the Ume.due�rq place antl Oue b�hs cwee�sl�ed. . <br /> Si nature antl T' •Nd Titla <br /> 29.DID 70BACC0 USE C 7 30.a ORGAN Op TISSUE ATION BEEN CONSIDEREO? 30.b wAS CONSENT GRANTED? <br /> X O YES NO � UNKNOWN YES � Np � VES NO <br /> 31.NAME AND ADDRESS CERTIFIER IPHYSICLW,COiiONER'S PMVSICIAN OR CQUNTy A OFiNEY) /Tyye arPniMJ � � . <br /> Leslie A. S r M.D " " <br /> 32a.REGISTRAR 32b. I BV R lMO..Day Yr./ <br /> �Y� AUG 2 51999 <br /> 1�- �q ��i�C 1; >�v � �k,e�,y�� y� - <br /> > � <br />