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� n � , � <br /> .m 7G A CO C7 C!� <br /> C � � � O -i 0 i"Pi <br /> S D � � �` �� Z "'� O � <br /> � ,� <br /> lm'� � �; �.: `-' -c Q � :� <br /> � � <br /> �c�s~� <br /> o '� <br /> t � � <br /> -+- � � �,, •,n <br /> � � rn � <br /> ."t F :;� �; �► m F--'' .n <br /> -'"t Y'` --� f� <br /> <', �- T�, ►--� ,� <br /> f� .. `� !-� � Q7 :� <br /> r � � <br /> m � � ....� -� �. <br /> r. « <br /> � � � Z <br /> (7 1 Cn p <br /> 0 <br /> Lot 10, Block 5 , in Wallich' s Addition to the City of Grand � <br /> Island, Hall County, Nebraska. <br /> � <br /> wt�n�rs coPrc��s nf w�aEV s�u.oF tr��e�siu r��n�r�un t�ur�t.��s <br /> SY5TE11�IT CERT�S TF�BELOW TO BE A TRUE COPY OF THE OR/GINAL <br /> THE NEBRASKA HEALTH AND HUMAN S�RVICES SYSTEM,VITAL STATIS _ <br /> THE LEGAL DEPOSITORY FOR VITAL RECORD3. ` `° - - � <br /> ; ='_-- . - -� - <br /> DATE OF/SSUANCE � _ - I J_"' "''��0`_`-^< <br /> �g � i i� � ��:� -_ ���, <br /> AUG 41999 ASS,�� -��-`�- _= <br /> UNCOLAI,NEBRASKA HEALTHAND H�AI�.SE1tVICES.SY� <br /> STATE OF NEBRASKA-DEPAR'[MENT OF HEALTH AND FiUMAN SB�ViCE,4I��k,?�SUP�DRT <br /> VffAL STATISTICS - ""-- - <br /> CERTIFICATE OF DEATH == - - ' = <br /> i DECEDENT-NAME FIRST MIDDLE UST 2.SE% - . -OF DEATH /MOnM.Oay.VNrI <br /> Male Jul 26 1999 <br /> <.CITV AND STATE Of BIRTH /Mnot n U SA..nams tounhy/ Sa.A -Last BiMWay UNDER 1 YEAR UNDER t DAV 8.DATE OF BIRTH /AbnM.Dey.YNr) <br /> v�les Wrner M�lWall�ee T��T �Vrs.l LO Sb..M05. ' DAVS St.HOURS� MINS. M,��••Cll 29 1931 <br /> IlQ L•11 YYl VC7 1'JGIl <br /> • 7.SOCIAI SECURTIV NUMBER Ba.FLACE OF DEATH <br /> 396-38-3283 HOSPITAL � Inpalism OTMER � Nuninq Home <br /> . -- - <br /> BD.FACtLITV-Nsms lUrwl msBNlwn,yiw�ss/and numWr) � ER Oulp�dsnt � ii�e�dence <br /> . <br /> St. Francis Medical Center � D0A � °`r""S°"'"� <br /> &.CI7V.TOWN OR LOCATION OF DEATH 8d.INSIDE CITV LIMITS Be.COUNTV OF DEATM <br /> GrCUAi 1$1CLL1U • Ys� � No � 11 <br /> 9a.RESIDENCE-STATE � . 9D.COUNTV Bt.dTV.TOWN OR IOCATION 9E.STREEi AN�NUMBER IlneWdlny Zi0 Codsl 9e INSIDE CITV LIMITS <br /> Nebraska Hall Grand Island 12 4 W 8th St 68 01 �"�* "°❑ <br /> �0,RACE-(e.q.,W�ite.Black.Amenc�n kWian. 11.ANCESTRY le.q..llall�n.Mexican.Osrmen,etcl 12.�MAHRIED ❑wIDOWED 13.NAME OF SPOUSE lH wAS.piw m�id�n n�ms) <br /> etallSpec�Nl ISpeelly) NEVER OIVORCED <br /> White American Patricia Norber <br /> 1�a.USUALOCCUPATION (GivekindolwakdpNdurinymatf 11b.KINOOFBUSINESSINDUSTRV 15.EDUCATION (Spstilyonlyh� prW�COrnpIMW� <br /> ol workxg�ib.sv�n Jrstirpol El�msnury a S�tonEsry 10•t21 Co4pa It-a a 5•I <br /> � 18.FATHER-NAME FWST MIDDIE LA$ 17. OTHER FIRST M�DOIE MAIDEN SUHNAME <br /> D2C. G�'ldY'12S W n,., yp� <br /> 18.WAS DECEASED EVER IIJ U.S.ARMEO FORCES?K�rP�n Wnfl �LINFORMANT-NAME <br /> I�es.�o.or unk.� W yes.qrva war and tleies W aemcee <br /> Yes 1950 - 1971 Vietnam Era Patricia Be ersdorf <br /> 19D.INFORMANT MAILING ADDRESS ISTREET OH R.F.D.NO..CITY OR TOWN STATE.ZIP) <br /> � 1204 West 8th Street� r � <br /> 20.EMBAI R-S NATV e 8 ENSE NO 21a.A1ET ODOF qSPOSiT10N 21D.OATE 21c.CEMETERV Oii CREMP fOAV NAME <br /> - ' Et�ergreen Memorial Park <br /> 03 �e���.� ❑Re��a� ; Jul 29 1999 <br /> 22a F NERAI HOME�NAM 2�tl CEMETERV OR CREMATOA�IOCATION CITV R TCWN STATE <br /> �Cremalion �Uorauor <br /> eine Fun r 1 nmah�.,�phr�� _ <br /> 22E.FUNERAL HOME ADDRESS !STFEET OR R.F.D.NO..CITV OR TOWN.STATE,ZIP� - <br /> � 3213 W. l�orth F ont St., Grand Island, Nebraska 68803 _ <br /> 23. iMMEDIATE CAUSE �- (ENTER ON ONE Pµ\1SE PER LINE FOR iai.Ib1.AND�cll � Intsrva'l D^s�wsen oneM an0 Oeam <br /> PART Q ' � �`,'l.�"� �{�l�'V � I Y � V I"��tiY!"a/ � � <br /> � � I <br /> lal � <br /> � OUE TO.OR AS A CO OU CE{�� � i Interval belw�en onael anA tleath <br /> �' '�rv w��1n s�-v� p�c�.vun.-�'� � 02 <br /> �v � � <br /> }( Ibl t <br /> DUE TO.OR AS A CONSEO NCE � �ntervai D�iw�sn onsat and Aeam <br /> � ,�� s--�.c� a ��,v��-►�' ;x 3 <br /> QZN::R pGWElChfi�- qN5�CendNlons eonRldNng t6ttx GeaM tiW nd relaled� PART III IF FEM.C�E.WAS THERE A 2a AUTOPSV 25.WAS GAS FERRED TO MEDICAL <br /> PAf�T PREGNANCV IN TME PAS7 3 MONTHS7 E%AMINe R CORONER? <br /> I I � � � <br /> ,� �Aqas�O�Sa� ves No � Ves No �es No <br /> 26a. � 260.DATE OF INJURV (Ab.Dey.Yr.J 26c.HOUR OF INJURV 26d.DESCRBE MOW INJURV OCCUAAED - <br /> � Acatlen� � U�+Oe�erminetl M <br /> � Swcba � Pendma 26e.INJURY AT WORK 26t.PLAB�Q�'I�NdB,RY%At�homp.larm.sfreet.laqory 26g.LOCATION STREET OR R.F.D.NO. CITV OA TOWN STATE <br /> � ❑ ❑ plhC S �I <br /> Nomicitle InvaSUgauo� Yes No <br /> 2)a.DATE OF DEA7H /MO..Oay.»./ 2Ba.DATE SIGN D /MO..Da.vr.! 2Bb.TIME OF DEATN �� <br /> �g � z6 ��= 2 � �9 M <br /> �`'�}, 27b.DATE SIGN /Ab..Oay.Yr.l 27c.7iME OF DEATM �O gg,�� 2&.PRONOUNCED DEAD I�Day,Yci 28d.PRONOUNCED DEAD (HOUd <br /> g� � �8 � M g w£� 2 � �G M <br /> �g 2)d.To Me bes�ol my knowle Ceath Cu at ihs Gme.tlete an0 DlaCa and Eue t0�he °�� 28e.On the pesis ol ezaminaMn �or' ,in opinqn dsalh otcurteA at <br /> causelsl sw�ed. 3 the time.Oa�e and Wace a e ro u I�a�ed. �/� <br /> �S�naNra an0 Title IS naNra antl Title � /' /�` <br /> 29 DID TOBACC USE CONTRIB TH DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN C NSIDERED? .b AS S NT G ED? <br /> � VES � NO � UNK x � � YES NO VES �O <br /> 31.NAME AND ADDRESS OF CERTIFIEp IPNYSICUN,C ER'S PHVSICIAN OH COUNTY ATTOHNEVI /Type a Prinf� <br /> Sitki M. Copur NID 211 W. Faidl Ave. Grand Island Nebraska 68803 <br /> 32s.REGISTRAR - 32D.DATE FIlEO BV fiEGISTRAR /AAO..O�y.Yr./ <br /> �..�� /'_ _ ei ir; � ��4 <br />