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<br />WHEN THIS COPY CAMMS THE RAISED SEAL OF THE NEBRASKA HEALTH AND Ht 40N SERVICES
<br />SYSTEMS IT CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE_ :FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI H IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE -
<br />MAY 0 6 2004 '200404736 ANL t,
<br />I�l�t3TA91FT &TAKE- R!'�GIiT'F�R
<br />LINCOLN, NEBRASKA HEALTH, ENYD N SERVlCF$W- STEM
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTN N_'.
<br />Bureau of Vital Statistics �— - h �, _
<br />CERTIFICATE OF DEATH 0 , � � e
<br />-DECEASED -NAME FIRST MIDDLE LAST
<br />SEX
<br />M
<br />'
<br />2
<br />3. June 11 1
<br />"WHIM,
<br />RACE WHITE, NEGRO, AMERICAN INDIAN, AGE-FASI UNDER 1 YEAR
<br />UNDER 1 DAY DATE OF BIRTH )MONTH, DAY,
<br />COUNTY Of -DEATH
<br />ETC. 1 B111FNDAY 1 YEAlb, MOs. DAYS
<br />NOUtb MM. "A"'
<br />White s. s..
<br />s<. 1 16.Jan. 26 1828
<br />=
<br />CRY, TOWN, OR LOCATION OF DEATH INSIDE CITY WAITS
<br />HOSPITAL OR OTHER INSTITUTION -NAME 11! NOT IN fly"", Give STREET AZ NUMBER 1
<br />SPECIFY YES OR NO
<br />n Grand Island }1. Yes
<br />id 912 West 12th Street
<br />STATE Of BIRTH (if NOT IN U.S.A., NAME
<br />CITIZEN OF WHAT COUNTRY
<br />MARRIED, NEVER MARRIED, SURVIVING SPOUSE / if wat, Olvt MAIDEN NAME)
<br />COUNTRY)
<br />WIDOWED, DIVO*aD (SWEPT 1
<br />its
<br />t e_
<br />+. USA
<br />Married I,. Edna (Schimmer) Stueven_
<br />SOCIAL SECURITY NUMBER
<br />USUAL OCCUPATION IGtvE RINo OF woem DONe DURING MOST OF
<br />KIND OF RUSII*SS OR INDUSTRY —'-
<br />WOMING WIFE, EVEN IF [1111110 1
<br />till
<br />12 508-03-19
<br />Ills. eti,red farmer i
<br />136. FArmi
<br />RESIDENCE -STATE
<br />COUNTY
<br />CRY, TOWN, OR LOCATION
<br />INIIBI CITY FAIN STREET AND NIJEARER
<br />o_
<br />IM Nebralk
<br />IA.
<br />Grand Island
<br />IN. Yes IN. 81 South Vine St.
<br />'FATHER -NAME Pont MWINE LAST MOTHER- MAIDEN NAME FIRST MIDD(E LAST
<br />C11, 0_
<br />o
<br />IiR. 8 South i t. Grand Island, be. b881
<br />FART 1. DEATH WAS CAUSED BY: [ENTER ONLY ONE CAUSE PER IN* FOR (p), jb), AND (c)j
<br />RETwttN ONSET .00 MAP.
<br />)B IMMEDIATE CAUSE
<br />(D, coronary occlusion
<br />( immediate
<br />EOMDITIONS, If ANY,
<br />WHICH GAVE RISC TO (b)
<br />IMMRDIAIE CAUSE /DI
<br />STATING 101E UNDER, DUE 10, OR AS A CONSIOUINCE OF.
<br />LYING CAUSE FAST
<br />(C)
<br />�
<br />`
<br />AUTOPSY
<br />If YES we@E FINDINGS CON
<br />TO CAUSE GIVEN IN PART I(o)
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />1 YES W No,
<br />lift
<br />SID[ttED ,N DETtaMINw.; CAUSI
<br />- O
<br />YES : N
<br />71
<br />ACCIDENT, SUICIDE, HOMICIDE,
<br />�
<br />{
<br />l•I'f
<br />CD
<br />OR UNDETERMINED (SPECIFYI
<br />ID
<br />2%
<br />206
<br />I01 M.
<br />}tl
<br />INJURY AT WORK MACE OF INJURY AT NOME, FARM, STREET, FACTORY, LOCATION I Steel? W R.P.D NO., CITY OR TOWN, STATE 1
<br />1 Stec)" Y!f W NO 1 Office EIDG.. EK. 1 SPECIFY t
<br />tt.. yeS 2M back and }M 912 W. 1.2th Grand Island- Nebr.
<br />CERTIFICATION— MONTH DAY YEAR I MONTH 0. YEAR ) AND LAST SAW MW /0110 ALIVE ON , DID/DID NOT V40W THE DEATH OCCURRED AT me PLACE. ON no
<br />PHYSICIAN: TO 1 MONTH DAY 7[AR EDDY AFTER DEATH iNpu11 DAR, AND, q MI MST
<br />I ATTENDED
<br />1218
<br />O OF MY .NOWL10041, DUE
<br />}it DECEASED FROM �}lll. 21T 2111 M TO DF1 CAUSI(SI STATED
<br />CERTIFICATION- MEDICAL EXAMINER OR CORONER: off T-1 EASIS up OF 001ATN THE OKEOIHI WAS PRONOUNCED DEAD -
<br />ERAMINATION Of THE BODY APID /OR THE INVISTIGATION, IN MY OPINION, DAY YEAR ,.Out
<br />DEATH OCCURRED ON THE DATE AND DUE TO THE CAUSIM STATED
<br />rL. A,. M. rn I 1 73 :: 7/
<br />_ _4 P AA
<br />CERTIFIER -NAME Try ►E 01 PRINT) DATE SICjNE0 I O.TN, D.Y, YFAa)
<br />238. Sam Grimminger CdL Atty. 6/25/73
<br />_
<br />MAILING ADDRESS - CERTIFIER sTRt e.r.D a oR T N —
<br />P. OR Box 367, a Isan$ bt3$Ol
<br />}„
<br />BURIAL, CREMATION, REMOVAL
<br />CEMETERY OR C I LOCATION C,n Ce w» sTArt
<br />SPECIFY 1 Burial
<br />Westlawn Memorial Par i,4, Grand Island NE
<br />240
<br />},,
<br />DATE /MONTH, DAY YEAt:
<br />June 14, 1973
<br />FUNERAL HOME -NAME AND ADDRESS , STRIPE OR t I D NO , CITY OR TOWN, STATE, RIP,
<br />ton- Sondermann,s,505 W.Koenig, Grand Islana, Pie. 6U801
<br />2N
<br />:sRLivings
<br />j EMR R- SIGNATURE 6 LICENSE NO.
<br />�ZSb rL —1-2 �- �vL
<br />REGISTRAR- SIGNATURE
<br />}M 1� / /� /�
<br />DATE IVED LOCAt REGISTRAR
<br />2w l�Ls
<br />..;
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<br />0
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<br />CD
<br />f10
<br />Cn
<br />Z
<br />WHEN THIS COPY CAMMS THE RAISED SEAL OF THE NEBRASKA HEALTH AND Ht 40N SERVICES
<br />SYSTEMS IT CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE_ :FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI H IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE -
<br />MAY 0 6 2004 '200404736 ANL t,
<br />I�l�t3TA91FT &TAKE- R!'�GIiT'F�R
<br />LINCOLN, NEBRASKA HEALTH, ENYD N SERVlCF$W- STEM
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTN N_'.
<br />Bureau of Vital Statistics �— - h �, _
<br />CERTIFICATE OF DEATH 0 , � � e
<br />-DECEASED -NAME FIRST MIDDLE LAST
<br />SEX
<br />DATE Of DEATH (MONTH. DAY, YEAR 1
<br />'
<br />2
<br />3. June 11 1
<br />"WHIM,
<br />RACE WHITE, NEGRO, AMERICAN INDIAN, AGE-FASI UNDER 1 YEAR
<br />UNDER 1 DAY DATE OF BIRTH )MONTH, DAY,
<br />COUNTY Of -DEATH
<br />ETC. 1 B111FNDAY 1 YEAlb, MOs. DAYS
<br />NOUtb MM. "A"'
<br />White s. s..
<br />s<. 1 16.Jan. 26 1828
<br />TR. Hall
<br />CRY, TOWN, OR LOCATION OF DEATH INSIDE CITY WAITS
<br />HOSPITAL OR OTHER INSTITUTION -NAME 11! NOT IN fly"", Give STREET AZ NUMBER 1
<br />SPECIFY YES OR NO
<br />n Grand Island }1. Yes
<br />id 912 West 12th Street
<br />STATE Of BIRTH (if NOT IN U.S.A., NAME
<br />CITIZEN OF WHAT COUNTRY
<br />MARRIED, NEVER MARRIED, SURVIVING SPOUSE / if wat, Olvt MAIDEN NAME)
<br />COUNTRY)
<br />WIDOWED, DIVO*aD (SWEPT 1
<br />its
<br />t e_
<br />+. USA
<br />Married I,. Edna (Schimmer) Stueven_
<br />SOCIAL SECURITY NUMBER
<br />USUAL OCCUPATION IGtvE RINo OF woem DONe DURING MOST OF
<br />KIND OF RUSII*SS OR INDUSTRY —'-
<br />WOMING WIFE, EVEN IF [1111110 1
<br />till
<br />12 508-03-19
<br />Ills. eti,red farmer i
<br />136. FArmi
<br />RESIDENCE -STATE
<br />COUNTY
<br />CRY, TOWN, OR LOCATION
<br />INIIBI CITY FAIN STREET AND NIJEARER
<br />t SPECIFY its OR NO 1
<br />IM Nebralk
<br />IA.
<br />Grand Island
<br />IN. Yes IN. 81 South Vine St.
<br />'FATHER -NAME Pont MWINE LAST MOTHER- MAIDEN NAME FIRST MIDD(E LAST
<br />Is. John stuft. n 16. Catherine Wenn
<br />INfORMANT- NAME- RELATIONSN /F MAKING ADDRESS ISMINT 00 R.F.D. NO., Cm OR TOWN, STATE, ZIPS
<br />IiR. 8 South i t. Grand Island, be. b881
<br />FART 1. DEATH WAS CAUSED BY: [ENTER ONLY ONE CAUSE PER IN* FOR (p), jb), AND (c)j
<br />RETwttN ONSET .00 MAP.
<br />)B IMMEDIATE CAUSE
<br />(D, coronary occlusion
<br />( immediate
<br />EOMDITIONS, If ANY,
<br />WHICH GAVE RISC TO (b)
<br />IMMRDIAIE CAUSE /DI
<br />STATING 101E UNDER, DUE 10, OR AS A CONSIOUINCE OF.
<br />LYING CAUSE FAST
<br />(C)
<br />PART 11. OTHER SIGNIFICANT CONDITIONS: CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED
<br />PART 111. IF FEMALE, WAS THERE A
<br />AUTOPSY
<br />If YES we@E FINDINGS CON
<br />TO CAUSE GIVEN IN PART I(o)
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />1 YES W No,
<br />lift
<br />SID[ttED ,N DETtaMINw.; CAUSI
<br />- O
<br />YES : N
<br />Of DEATH
<br />I%
<br />ACCIDENT, SUICIDE, HOMICIDE,
<br />OF INJURY (MONTH, DAY, .e At 1
<br />HOUR
<br />HOW INJURY OCCURRED ,ENTER NATURE Of INJURY I» PART , OR PART ,,, STEM /U
<br />OR UNDETERMINED (SPECIFYI
<br />ID
<br />2%
<br />206
<br />I01 M.
<br />}tl
<br />INJURY AT WORK MACE OF INJURY AT NOME, FARM, STREET, FACTORY, LOCATION I Steel? W R.P.D NO., CITY OR TOWN, STATE 1
<br />1 Stec)" Y!f W NO 1 Office EIDG.. EK. 1 SPECIFY t
<br />tt.. yeS 2M back and }M 912 W. 1.2th Grand Island- Nebr.
<br />CERTIFICATION— MONTH DAY YEAR I MONTH 0. YEAR ) AND LAST SAW MW /0110 ALIVE ON , DID/DID NOT V40W THE DEATH OCCURRED AT me PLACE. ON no
<br />PHYSICIAN: TO 1 MONTH DAY 7[AR EDDY AFTER DEATH iNpu11 DAR, AND, q MI MST
<br />I ATTENDED
<br />1218
<br />O OF MY .NOWL10041, DUE
<br />}it DECEASED FROM �}lll. 21T 2111 M TO DF1 CAUSI(SI STATED
<br />CERTIFICATION- MEDICAL EXAMINER OR CORONER: off T-1 EASIS up OF 001ATN THE OKEOIHI WAS PRONOUNCED DEAD -
<br />ERAMINATION Of THE BODY APID /OR THE INVISTIGATION, IN MY OPINION, DAY YEAR ,.Out
<br />DEATH OCCURRED ON THE DATE AND DUE TO THE CAUSIM STATED
<br />rL. A,. M. rn I 1 73 :: 7/
<br />_ _4 P AA
<br />CERTIFIER -NAME Try ►E 01 PRINT) DATE SICjNE0 I O.TN, D.Y, YFAa)
<br />238. Sam Grimminger CdL Atty. 6/25/73
<br />_
<br />MAILING ADDRESS - CERTIFIER sTRt e.r.D a oR T N —
<br />P. OR Box 367, a Isan$ bt3$Ol
<br />}„
<br />BURIAL, CREMATION, REMOVAL
<br />CEMETERY OR C I LOCATION C,n Ce w» sTArt
<br />SPECIFY 1 Burial
<br />Westlawn Memorial Par i,4, Grand Island NE
<br />240
<br />},,
<br />DATE /MONTH, DAY YEAt:
<br />June 14, 1973
<br />FUNERAL HOME -NAME AND ADDRESS , STRIPE OR t I D NO , CITY OR TOWN, STATE, RIP,
<br />ton- Sondermann,s,505 W.Koenig, Grand Islana, Pie. 6U801
<br />2N
<br />:sRLivings
<br />j EMR R- SIGNATURE 6 LICENSE NO.
<br />�ZSb rL —1-2 �- �vL
<br />REGISTRAR- SIGNATURE
<br />}M 1� / /� /�
<br />DATE IVED LOCAt REGISTRAR
<br />2w l�Ls
<br />loo, i
<br />Lot Three (3), in Block Six (6), in Claussen Country View Addition to the
<br />City of Grand Island, Hall County, Nebraska
<br />
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