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C'") O <br /> J� N � . <br /> tt� <br /> -- ,�� <br /> �N�C�PY GA/tIZES THE RA/SED 3EAL OF THE NEBRASKA//Eq�TH ANp N�p�q��/��s � <br /> S1^STEII�?QERTFE3 TFE BELOW TO BE A TRUE COPY OF THE OR/O11W�,L:��y�py�TM � <br /> THE NEBRASKA HEALTH AND HUMAN SERHCES SYSTF�VITq�gT <br /> THE LEOAL DEPOSITORY FOR VITAL RECORDS ����M•H�S <br /> DATE OF/33UANCE -_ �/� ���� <br /> - 1v*^�`°"it=� <br /> OCT 11999 �- - g� <br /> unrco�nr,�eRa�u -'�� ���s�+� <br /> r�atrH����� <br /> 99 109836 _- =- _� .�=- <br /> pHSase(vs)REV.�-s�g � STATE OF NEBRA�HA ,� <br /> DEPARTMENT OF PUHLIC HEALTH. .� <br /> EnucwTTOx wrm w�,� DEPABTMENT OF HEALTH �9�� <br /> Bnrextn ot Vital StatLstics �� <br /> sntTx xa 126._..__. CERTIFICATE OF DEAT$ sTwrE gu,� xo_..._............:..... . <br /> .....:..__............ <br /> �.nwcc or�cwn� � - z usus< Rcs�ocrcc�A.........,rs.d. r�:..r:�.r�«.:R.:�.� . <br /> s. COUNTr � . . -�� �. STATE D. COUMTY . W�n�wiw) <br /> -- Ha13 : nr- !,- Nebr. Hall <br /> �D. CITY,TpWN.011 IOCATqN . . � t, �ENGTH.OF STAY IN�ID .t.CITY,TOWN,OR LOCATqN � � . � <br /> j . . . . , . � . . � . .. . . . <br /> � f. NAME Oi (/��j��py�����Mbtu) � � � d.�STREET ADDRESS <br /> MOSlITAL OR � � . � � � � <br /> � INSTITUT1pN 6zz ��Itest �Louise���St .: � 622 West Louise . St. ��� �� � � � : <br /> t. �5 PLACE pi pEATN INSIDE CITY UMITST ,YES NO❑. . . . e. �5 REStpENCE IIKIDE CITY U�:T51 YE . . . . <br /> � NOQ �' FARN RESIDENCEt YES <br /> 3�. NAM[OF � .fYrat - � � � N� � . <br /> D[CU3[O . . � � �jl�t . � L� � � 1. DATE MowU � Dey � Y�a <br /> tTrv�o.y.r�r� or 7 1960 <br /> Jesse R. Gore ��TN Au <br /> 5. �%. � � 6. COLOR 011 11ACE � 7 � •. OATE Oi lIRTM � � � <br /> - � � ..� MARRKD�� NEVER MARRIED❑ . . 9. AGE(Is�[w� li UMOER i YG1t yppER=�NRS_ . <br /> ��B � �il�tE.� : .WIOOWED❑ . DIVORCEO � . � � la�t AirtAltll XwW D.w� .Nww Y:.. <br /> 10�. USU�I OCCU►ATpN(Ci�t RiMo/�onk b�s IOD.KINOOi�USINESSOR INDUSTRY 11 B�TM►LACE(Sl��Jorriq�touMr�)� �j. pTiZq a w�T ODt�rtRYr <br /> fr•i��n�af yra4ls/�k.nes iJrdisN) <br /> armac3st . Talma e Nebr. <br /> � 13a.FATNER'S NAME � � D• � S•� A• <br /> � . � 13b.MOTMER'S MAIDEN.NAME � � � I�. NAME Oi MUS�AND OA W�p[ . . � � <br /> e H. Go e a ��ne .atcliff is:ath �n Keller Gore <br /> IS. W�S DCCEASEO EVEII IN U.S.AIIMED i011C[51� 16. SQCIAI SEWRIT1r Np, p..�N�pRq4NT. <br /> I YII.M•I Y�y�l Il1 rn.�iM w�.Ltr�N�wsyr) � � . . . � � �Atlrtl! . . . . <br /> � 1�. CAIKt OI �[ATN(Ewfo�1/oiu n�w t(wslN+(�).(�).�nf.(c).� �� . O a ' l�eb <br /> � ►�RT I. DEATN MAS CAUSED�Y: � ��L /) � . INTERVAL fETWEEN <br /> �MEDUTE CAUSE (�) _t�i� � !J?� p A i✓/�f?�/ C�/C���? L i�S•,?�lc� OMSET ANO TM . <br /> ���� i . <br /> Ceweitkwi.f/rnr. ouE To (6) / <br /> �v4icA Otst ru'� W <br /> �Do�f teax (eL <br /> KNt�/ tAe �wln- <br /> � l�i�� nrx lwl. �E TO (c) <br /> ►A11T 11.OTIIEII SKNKIGWT�p�qTpNS�Mi�l�►IN��p p����..�UTED TO TM(TEItM11Ml dSGSE Cq/p1i1pN GJYEN IN►MT 1(�) . WAS.AUTO►ST <br /> H< <br /> tl � � . . . � . � /ERiORMEDt � <br /> F 20�..ACC�DfMT SUKIDE NpMIt10f 200. p(5�RlaL Npyy'tNS:JAY OCCUNRED. (Esftr f�atutt oJ�njrry iw Pwf 1 or Pmt//o/ifr�!l.) rES❑ NO Q. <br /> W ❑ ❑ � ❑. - . . . . � . . <br /> lJ <br /> � 20t TiME ov Horr NmuA.Dq.Ytp <br /> INJUIIY �.fR.. � <br /> S P.w. <br /> W <br /> � �20/. INIURY OCCUIIIIEO �lt.KACE Oi INJURY(t./..h1 M�AeYt Apw�t. 2% CITT.TpWN.OII LOCATqN CpUNTY <br /> WNIL[AT NOT WNIIE /�A.l�wy.atrtd.�Q[et plf�..�tt.) STATE <br /> � WORK � AT WOIIK � � . . . .. . � � . . <br /> Z�• !�tt�nd�.!th�d�a�sl►dlrorn ,to � •nd lut uw� h�i/ir�on a <br /> •. D��M oce r�d�t � �� m on th�d�t�• I�Lw�;�nd to tM D��t o/m�Rnow/�dp./rom th• uN��t�t�d. <br /> �.SIOMA R[ (Dt/►a 0►H/lt) � �/I/�' 2?D. ADO � . <br /> 22c. DATE StGMEO <br /> � ' �'-c�-�Q <br /> 23a. s1Mt1Al.q1ErI111oN. 23A. DAT[ �. � . NAME OF CEMETEIIY.OII CREMATORY � � . 23f.IOCATION(Cif/.lo�os.or cornlYl � (SYatr) <br /> NEMOV l( � tif�l . <br /> Bur�� 8-10-60 Grand 1s1s� Grana Isl�nd iVebr. <br /> N. DATE II[CD:�Y R[Gt5T11A11 IIEGIS �I1'S SIGtlA:�ll! , � . � Z1.NAME OF MORTUARY �� � <br /> �DORE55 <br /> AUG 1 X 1 - , f ' Livir�ston-Sorldera�nn Grand Isl�nd <br /> ar o _t rteen .,�, -----— <br /> , o e oun y u v a on oi e Sou a of e ou eaet Quer�er <br /> (Sl/2SE1/4) of Section Stxteen (16), in Township Eleven (11) North, Range Nine (9) West of <br /> the 6th P.M., Iiall County, Nebraska more particularly descrlbed as follows: Commencing at <br /> a point forty (4U) feet easterly and forty (40) feet Northerly of tt�e Southwesterly corner of said <br /> Lot Thirteen (13), the real place of beginning, running thence easterly parallel wlth the <br /> Northerly boundary line of Lonise Street, for a distance of Sixty-tive (65) feet, thence running <br /> Nortl�erly pnrallcl witl� the Easterly bnunclary line of Cleburn Strcet, for a distance of Sixty-six <br /> (66) feet, running thence in a Westerly dlrection, parallel with the Northerly boundary I(ne of ; <br /> i.n..:en cfwnn{ r.... .. .l:,.a_--- -e c.:--�--.. ,��. _ - - - - <br />