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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAM SERVICES SYSTEM, IT CERTFFAES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD-ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA TISTI'O�_ nW,_-U ICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE JUN 2 8004 ASSISTAN€!I SI$f RAR LINCOLN, NE SKA HEALTH ANDWOMAN SERWCES SYSTEM 200406490 - • STATE Of NEBRASKA — OEPAIITIEW OF IWALTH CERTIFICATE F� 95_ 9726 L .RNAE. tASr 2 FEE a OITEp OfAIN /lA.w D.M Tffq Gene Leroy Buckles Male August 4, 1995 NQ Af�I.f�Ifl/F_ f, Am*LmM1Oft IIIDwIt YEM tNOwT WT' f.OATEOFUIWI. A1.IRDy Y." Bed Cloud; Nebraska IW.1 71 January 13, 1924 !41106 OAYE I it1101MM' 1NM TIIAMEIt Y PLACE p OEAM IIoErTrK ®..1,,. 0-m ❑ ML.•f T 333 = 24 2370 ❑ SID..... ❑ 1....- ,.., .»...........,�,,.�., Vi► Medic Center, Grand Island, NE ❑ oDA ❑ a,,,,�, oft 1N ad sRSOE CRY LIMITS r p DEATH `Grand Island, NE w A ft 00110101FIC0. WFAN 16 Coulm ft slow, Poe"Am owkavowdow f. MMCRVLWW Nebraska Hall Grand Island 2219 N. Huston Y,. ® M. ❑ M/.fKII,�IAAPNIfMf1.WI 11 Mf•sIMI/,RN Ntl a to MAR1S0 ❑ fa 10MOFSPOM /00/MOM4.Osaw Tom"' White Stre"aish /Irish /Penn.Dut h "�' mMDRCED Lucille Maxine Harthan TI6 UwMl0001AATCN IOA,ARIf/Mfl.fwrAl.rA1.r Tq Im OF Dump*" 09"T" "Agriculture IS EDNCX"ON ,df�I gMk@W #Arm FPlant Manager 5 0i1 I►Is crMM owe Trl iM%4 N Amm -wm FEW Is001! MfT IT NIOTHE/1 FIRST /ADDLE MAOEN EIwllla dec. ; Paul - Buckles Ellen Anderson- 0 IMAf Decamm -� IM•MR►wI.•N am N U ARMED FORCES? 1. IfM„wduftem" •tl,�f IW I IfA NFORIwn • NM* - as 3 23 43 -2 19 46 I Lucille Maxine Buckles tm INFORMAINT 1MENOAOOREf6 MTIIEETORRfa00. a"OnTOWN STATE a" ' 2219 X Huston. Grand Island NE '68803 >0 21 ►LETN000FDrtPOfTr1014 214 DATE ttn CEMETIM ORCRGMTORY NAME ®�+ ❑— 109 tlawn Memorial Park �ow _r" iIA dl CINVARMLOCATION C GRTOWN STATE Purmwal Qmnd Ialand, Nebr� S. 16TREET OII R,DI M0. CIIY OR fOWR STATE 3'11 1123 West Second, Grand Island/ NE. 68801 as , IMMEDIATE CAUSE IENTER ONLY ONE CAUSE PER LINE POR nt fM MOM 1 IrAwNR.Irf.AO.Ir.ro..Iu PII/TT Adenocarcinoma of stomach -Weeks DUE TQ oR ASA COMMIENCE OF 1 .frw.Ilu..n rill sro e.r� DOE TQ OR AS A CONSEQUENCE OF 1 M.r•.1..IP..II ur1 am 41/� 1 1 SIGNIFICANT CONDITIONS • UnOWS ooA.AI,II f b h fN/I W 1101 M.I.f PART ■ I FEMALE. WAS 11ERE A N AUTOPSY =CASE REFEIMED TO MEDICAL PWIF f PREGNANCY N THE PAST B HONER/ 125 EKAI/ER pi dOR011ER+ ft moo." r« n - F1 Y.s n No r« No of DAD DATE p NAOM AI.. DIP nJ 28, 1"A Di "AIRY 2ff DESCRIBE HOW IMr KA MWIRED [] AMON ❑ �-•-f N ❑ f.fr. ❑ P.I- 300/MAYATWORK 2f1 - pllnrrf IrI. R.w lstOr 2%LOGATION STREET OR RFD NO CITY OM TOM STATE 774 DATE OF DEATH A b DIP n) 28A DATE SIGNED Aft Dw Ir, 2.. TIME OF MATT N` 37L QA _ vOMD A/. I W c% 77C THE OF DEATH 2k PRONOUNCED DEAD Ab DNt h1 2ff PRONOUNCED DEAD Abel 1. ... • $Y Y 71t if .frMPIP YI.M.fFf ■M Or..IIf .III W.bM 2ff OnfMMMd MA.IIIYl M,1 MA111f1.d►RRAP Of.IfIAfN/1.YL'I.I,P• '. comm"INNA / 4 6.N.Afmm SI.os Mf" looscmMIMt4Nl AMT ,M T wl DROlOM0�0,+0}UM OONTNwFFE lOM0EAIM NA1 ORGAN OR TISSUE DONATION KM yA:4��`jy:.yti ❑yUA. Aa. p. .yaR 4-# .. "❑ TTEEfE YE6.• ® COMIDEAEOT 204 :� .NT K - -` :. WASCOMENF OR NW NM ✓! s ../ .. ❑ YES •..• p MIM�MK fMYE1pIN ORCOUMIPATTOW"•)7PMRAq 1 f CP nter, 776, N roadwe11 Grand Islandi NE 68803 . :.: •, ;..:: ,_. a2, DATE PLED EYREOMTRAIT Aft DIKMJ WAIF • AUG 2 11996 i