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JUN -8 -2004 12:32 FROM:GI SOUTH 3083845657 TO:3e55184 P:1 WHEN THIS COPYCATS TME RAISED SEAL OF TPE NEBRASKA HEALTTI AND HUMAN SERVICES SY3TTW fT C ERTAWS THE BELOW TO BE A TRUE COPY OF THE O)WOM i RECORD ON FILE WITH THE NEBRASKA HEAL Tit AND HUMAN SERVICES SYSTEM, VITAL STA TOMS SEC770M Wh7CH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS 200405657 DATE OF ISSUANCE DEC qo�l{ ANLEYS. COOPER D LL 4I ASStSTA1YT STA7F REGLSTRAR LMCOLN, NEBRASKA HEALTH AND HLOWAN SERVICES SYSTEM 'STATE OF NEBRASKA- OF-PART A T OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT VITAL STATISTICS CERTIFICATE OF DEATH I DECEDENT -.NAMF FIRST M1011LE LAST SL- 3. DATE OF DFAI11 %%,At tL. YM.I Sharon Ann Berger Female November 27, 2000 4 CITY AND STATE OF BIRTH IdM,n USA w CaLNWrj AGE 't" lGw4#V VNDCA I YCAR UNDER 1 DAY 0 DATE OF B1R7M .Afb,,A LNY Ynp.) -- 112-11-43 Grand Island, Nebraska 1 I January 8, 1957 Mas DAY` Sc HOURS MINS 7, SOCIAL SFCURYN NUMBER 0a PLACE OF DEATn 505 -82 -7076 •Iosarn� ❑ Ina..en OTHER ❑ N &arc Ho.N: 2IG DATE -... ® L. OUO2k n ❑ Ae~V 'j 6b I ACIITY - Na (71.p.nfMwiln. g.vr,neee t ny.rr.OaYJ St_ Francis Medical Center ❑ DO" ❑ �I "" - _ A, COY tOWN OR LOCATK)N OF MATH Ad INSIDE CITY LIMNS Be COUNTY OF DEATH Grand Island Ye' 0 NO ❑ Hall-_ ,11L AFRIMNT.'[' - SPATE _ 9b roATY yr, CRY. tOWN OR LOCATION 90 STREET ANO NUMBER mcaaGy7T. (.'..frl M. INSIDE CITY 1 nw1:: Nebraska Hall Grand Island 4385 W. Stolle Park Rd[ Y� ® Na ❑ 10. MACE•1 -4-MW BW;A Ame anb"an, 11. ANCESTRY h n~. Mc•ra^. Gmn Aral 12 Ig MAQnu ❑ WIDOWED 13 MAMEOFSPOVSF ;Nmla— Mautrnnimwf AIEI lsmu YI White ISaesM1 American Iftj,mimdofnodonAd �,J NEVER 01 ED MARRED El Jams 144 USUALOCOVPATION "N f 19h KIND OF BUSU+ ?SS INDUSTRY t5 EDUCATION (Swev v%ETA 7AaA 1,01 Al dwr.AF.II NG ..+•- •^"••••di Advertisin Newspaper - �a",. 0 101 wy I{ Le Y Clarence Banner Eva Kuhn 10. WAS DECEASED EVER IN VS ARMED TOI EET ASIA NFOFAMNT -NAME. I .v � ��•! IA ycs. o.'e war aM daw d A.mYwy, , James Berger Iyb INFORMANT MAILING ADDRESS ISrREFT OR R F D NO.. CITY OR TOWN STATE ZIP) 4385 W. Stolley Park Rd., Grand Island, NE. 68803 M LWALFALS SIGNATURE A LICENSE NO 21. MET-OD DA DISPOSITION 2IG DATE 21e CENFTCAY CRCakMAt')R. NAME Not Embalmed ❑ N,FN, Nov. 28, 2000 Central Nebraska Cremation 210 CEMETERYORCREMATOM'LOGATRNJ 1.1711 OP ICY^ 5TATF M FUNERALIIOML NAME Apfel- Butler- Geddes Nomm~ ❑DW&W Gibbon, Nebraska 22h FUNERAL HOMF ADDRESS !STREET OR F1 D NQ OITT 01% TOWN STATE. 21P1 1123 West Second, Grand Island, NE. 68801 M. IAMEDIAT ICNt ER ONLY ON� E CAu� SF PFR N FI,11RM1 C. n " -0e m- PART � � r W _ - - -- - r DUE TO, OR A.R A CONSEQUENCE OF �� nAnvt4 lx7twMn t t A -It rw.n IW DUE TO. OR AS A CONSEQUENCE OF teI _ ImCval be%w ., 0-MI SIC MJ7 BART V1 "L" NIU —ICANT GD140MON5 - c4e**ns .0 -ft k19 MRIF AAa4 NISI TMIld II 20. DATE OF NJURY jAft Day. ❑ AcGIdmK Q IIIIdAMrn,. ❑ swC * 0 PAllding 26e. INJURY AT WORK 2V ❑ 1, m— o InvAyKjAYa. Yan ❑ NO ❑ r {{ MI. DATE BIONED R y 27d TO 4'e bbst a1 IaY no ALIT �C uA�xysl:utbd. PART IR IF FEMALE. WAS THERE A 2c AUTOPSY - -- n WAS CASE PREGNANCY IN THE PAST .1 MONTIL57 EltAraNER IAum 10.5A1 Yes Na Y. M, YC 26S DESCRIBE MOW WYJURY OCCURRED M shlet%dwy 18O.LOCATON SI REET OR RF D. ND CITY OR TOWN Oa.• Y•I T>ty, TIMFOF DEATH Mo u STATF .M 275 LIMEOFDEATH z JtC 2lk PRONOUN= DEAD !ab. aw Yr.1 280. PRONOUNCEDDEAD TI. DID TOBACCO USE CON TRIBUTE TO THE 13EATHI QYES [Z -0 ❑ UNKNOWN 31 NAuL AND ADDRESS OF CERTIVIGR PHYSICIAN, CQR01NERSPHyS Don -kid GR. W;r-�A M D 32a4 FIEOISTRAR �T_ 3:3()A,, ! � � � M an0 EUc n QM ° - u 26! CIA IIIe bat d etuminxbn an wIgFean• n my mom. OeaA+nc�3A.sd al p� / l ,.., - Ptc mmA. dau An0 aAts An0 OI�e a IIK ceuzcl.l R.itM 1 fJl 4 P+0 Tft AS ORGAN OR TISSUE DONATION BEEN CONSCEREDT 006 WAS CONSENTGRANTED' C3YES [ NO ❑ YES NO COUNTY ATTOaNEY1 frp"&Aron 'rt, ^w—. FBI 0 0cnd 1.s(d, AIE a� // � 32b nATF FA-ED BY 4L(iISTaAa oft My. YFJ