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WHEN THIS COPY CARRIES THE RAISED SEAL OF ME NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, ITCERTIFIESTME BELOW TO SEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERMCES SYSTEM, VITAL:STATISTICSSECTION, WHICH IS.
<br />THE LEGAL DEPOSITORYFOR VITAL RECORD& ;y
<br />DTEOFryry ISSUANCE 200405078 1 /^,',E °EDIp
<br />DEC V 1 H ZOO1 ASSI�STATEREO9OTRAR
<br />LINCOLN, NEBRASKA HEAL THAW MILAN SERVICES SYSTEM
<br />SIAIti OF NF.BM3KA- UlYANIM6Nf OF FffALiHANO FNM.ViSGRVICG9FPIAHCE AND$WPO T
<br />VITAL STATISTICS _- -
<br />CERTIFICATE OF DEATH b 1 14065
<br />1 DecmExr. NAME FIRST MIDDLE __.. - "us1 F x. s D.TEDF DE.1x A,., -wn D,. .a•rl -
<br />Jack Stanley Madsen Male December 13, 2001
<br />" lA.,
<br />Omaha, Nebraska IG" 71w MosEF wv HoDRS Mw sOctober 26,a 1930
<br />, nTCl.1 111. I SIR E, 1LACE OE DenrN -- — _... - --
<br />505 -30 -0640 NEEPTAL ❑ 1ro,w.I _. ® N.. q •me
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<br />IN 1�'. N-e- w.e,11..r..M.1«ns . rr ❑ rxo,w•.I ❑ UAA,Ax'.e
<br />'St. Francis Skilled Care Unit ❑ AAA ❑ °"°11S""°'
<br />IF DI1v TOWNON•oc.TNANDFDFAIN - INaDUlT -111T COUDTYOIOFATH
<br />Grand Island, Nebraska YEA n w ❑ x. Hall
<br />III RE111ExcE -sTArE w couxn _ -. _ - -TOWN Ox LUC. N.N AND NDMRF Tsoec —Mrs
<br />Nebraska Hall Grand Island 2314 Valdeapo.R Ave. 68803 v.® NO
<br />11, WII""Ammran,mian s Inq •zlw. 0-TA' 0111"1¢1 Iz ®MFPoEO- ❑WIDOWED NAME - OFSfoDEE in He pwnwwir.a,vr
<br />.1=IIIAAWI lWhite 1so11,nIR American ❑NE 'Donna McGee
<br />1141 ISUALIATUAFTER, UTAANwUwAAW Mae-
<br />Insurance Agent Insurance AgencyEI "'"" " °'� "�s1�w.r alE1 MIS c�.•uwv
<br />EATISA NAME Ewsr MIDDLE -LAST - MDIDEx ,msr .1101E Ol1P♦•an[E
<br />Herbert Stanley Madsen Marguerite �3ipH.ala-
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<br />Ils INFORMANT TIME
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<br />NO -
<br />Donna Madsen_
<br />Mb '.' —AN' umwD .... III Is IUFFroxn,D AN CITYINTOwe SmrE nw
<br />2314 landergrift Ave., Grand Island, Nebraska 68803
<br />EMSHMEF.Sgx4D1E I.CI xD .1OUT F0L,TSn DATE m CEMI11AI OF LPEMATOPV NAMES
<br />m Not Embalmed #1071 L] 8-1 ❑R.1or11 Dacalber 14, 20011 Weet]arn Mmumal Pads Cms berry
<br />22, FUNERAL HOME NAME cFMFlFnv nx cFFMAmev LOGanOx D•11 A. Wx STAFF
<br />All Faiths Funeral Home Oc' ^ ""°" ❑°o"" Grand Island, Nebraska
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<br />:CIA ADNERALHOMEADORESS ISTRESTOR RE D NO CIT. OR TOWN SATE SIR -' - -'
<br />2929 S. Locust St., Grand Island, Nebraska 68801
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<br />IwrEU IN, Y FIT CAUSE IN L.E 101,'1 M AnD IT" ANA.. -.A-0, n,m. ne.,.
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<br />NAME IND ADDRESS OFDE1llFlE IlMVSCUx, COMA
<br />Anne K. Morse M.W.. 7:
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<br />FEE ' /L�no
<br />Custer Ave,
<br />Grand Island HE 68803
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<br />DATE F WA LAY
<br />DEC 1, 7 2009
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