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P I PULP STATE OF BI•ITH /!,tltn L'SA MOMCI)u,W,
<br />Gibbon, Nebraska
<br />505 -58 -7437
<br />6D FACILITY Name rM rvN.wyNy tell dye yetel J,,c- u,nOM)
<br />West. Hall Co. Good Sam. Centez
<br />& '17. TOWN OH LOCATION OF DEATH
<br />Wood River
<br />9a Rf S,DENCE STATE —'�9t COUNTY
<br />Nebraska Hall
<br />ID PACE ':eq WnAt Biec. A- ,e.can Ylyan TI ANCESTRY,eg g4yl Max
<br />etc SDtc•tpWh to I JYI /Dani
<br />17 ,ISUALOCCUPATION G,wkwdPf A,,r*d"d6el,ntdyT 146 K
<br />of age„Ip ale IYan V rowed,
<br />,re** -.; .r unk , 1 ff yes 9,,e we, am dales d Aarw_"l
<br />No
<br />19t 'NFORMANT MAILING ADDRESS
<br />1211 Sherman Ct. N
<br />20 EMBALMER . SIGNATURE 6 LICENSE NO
<br />Not embalmed
<br />;22a FUNERAL HOME NAME
<br />Apfel FtIneral Hane
<br />IY,s, 91
<br />Sp- MOs - - -- DAYS 11X-
<br />PPE GNANCY III THE PAS, WM.ITMS1 Ea•tAMNEF F•
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<br />6A PLACE OF DEATH
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<br />32. REGISTRAR
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<br />LOT 5, IN BLOCK 1, DODD 6L MAR. TT'S ADDITION TO THE TOWN OF WOOD RIVER, HALL
<br />CWM,
<br />]AP:RRA.SKA
<br />WHEN THIS COPY CANWS THE RAISED SEAL OF THE NEBRASKA S
<br />SYSTEM IT CERTFIES THE BELOW TO BE A TRUE COPY OF THE R% L CORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL $T,�_ NCH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />--
<br />DATE OF ISSUANCE
<br />200407666
<br />JUL 2 3 2004 = A* R,
<br />LINCOLN, NEBRASKA HEALTHAIW. 40
<br />STATE OF NEBRASKA- DEPARTMEM OF MALTH AND HUMAN SERVICES FMAWMA ' SUMo f
<br />VITAL STATISTICS - =-
<br />CERTIFICATE OF DEATH
<br />i DECEDENT NAME FIRST MIDDLE LAST 17 SEX 3 DATE OF DEATH 4116 —Dar ✓aVl
<br />--
<br />P I PULP STATE OF BI•ITH /!,tltn L'SA MOMCI)u,W,
<br />Gibbon, Nebraska
<br />505 -58 -7437
<br />6D FACILITY Name rM rvN.wyNy tell dye yetel J,,c- u,nOM)
<br />West. Hall Co. Good Sam. Centez
<br />& '17. TOWN OH LOCATION OF DEATH
<br />Wood River
<br />9a Rf S,DENCE STATE —'�9t COUNTY
<br />Nebraska Hall
<br />ID PACE ':eq WnAt Biec. A- ,e.can Ylyan TI ANCESTRY,eg g4yl Max
<br />etc SDtc•tpWh to I JYI /Dani
<br />17 ,ISUALOCCUPATION G,wkwdPf A,,r*d"d6el,ntdyT 146 K
<br />of age„Ip ale IYan V rowed,
<br />,re** -.; .r unk , 1 ff yes 9,,e we, am dales d Aarw_"l
<br />No
<br />19t 'NFORMANT MAILING ADDRESS
<br />1211 Sherman Ct. N
<br />20 EMBALMER . SIGNATURE 6 LICENSE NO
<br />Not embalmed
<br />;22a FUNERAL HOME NAME
<br />Apfel FtIneral Hane
<br />IY,s, 91
<br />Sp- MOs - - -- DAYS 11X-
<br />PPE GNANCY III THE PAS, WM.ITMS1 Ea•tAMNEF F•
<br />Op COFLONE
<br />6A PLACE OF DEATH
<br />-
<br />Ka : 26D DATE OF INJURY ,W Day V,1 26, HOUR OF ftX`RV
<br />rIOSPRAL
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<br />W INSIDE CITY LIMITS
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<br />Hall
<br />Kan. Gw-w MCI 12 O MARRII
<br />sh NEVER
<br />MARM
<br />FYO OF BUSINESS INDUSTRY
<br />ealth Care
<br />.AST 1 77 MOTHER
<br />mood
<br />19a iwomamw NAME
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<br />Bruce Hove
<br />10 CR'c ORTOWN STATE ZIP;
<br />May 11. 2003
<br />a DATE OF BgTH ,Wpgy Dar Yawr
<br />MN5 1 Nxi 1 4, 1912
<br />OTHER ® Nus.w r¢i•r
<br />Dills, sow'.
<br />R000enct
<br />1311 Lilly St.
<br />!O'? WIDOWED 13 NAME OF SPO i
<br />DI! 44CEO i J. Gera]
<br />15 EDUCATION ;Spac,NM
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<br />68883 Y« Yf - 0_
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<br />ED Burial D Re,•wva - 5/12iO3 Cent LR�.b Crw. Seri%
<br />21P CEMETERr OP :PEMaT^wv LOCATION C +T r -P •OWN STATF
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<br />® Crcnatge Lj Dmal.v
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<br />�..'JIM IrI IJH HFD NU CITY OR TOWN STATE ZIP) -_ -- -
<br />411 West 11th Street P.O Box 126 Wood River, NE 68883
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<br />3 IMMEDIATE CAUSE ENTER ONLY ONE CAUSE PEP LINE FOP a , AND,c• tny, -.J: lleAra.n b+f:l1 .•r y,M:
<br />PART ��
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<br />DUE TO OR AS A CONSEQUENCE OF
<br />GTMFR S,ONIFY'AN7 fONUIT1pN5 CaHn a+1CMM,bUn e1e •lea'y. DUI nDI •Nate VAFT II:u FFM ._ .:TPS• 125 HAj' AjI REFERREL-1 ME0C.4
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<br />273 DA rE OF DEATH MP Day I,
<br />in- DATF SrNED 441 Dae - :291- TIME OF DEATH
<br />271, LATE SIGN Day v 27• TIME OF DEATH
<br />7g ITN. Pi . OUNCED DEAL' M: Ey, v,. 7EC PRGWC.._�.; E.: -�aD
<br />171 r,;.lne
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<br />29 '1 •OBACCO USE CONTRIBUTE TO THE DEATH+ 30a HAS ORGAN OR TiSS.IE _:NATION BEEN CONSIDEPED' 3Dt HAS CONSENT GRANTED'
<br />u •ES {I •M. UNwyOWN I G
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<br />3' NAME AND ADDRESS OF CERTIFIER PHYSICIAN CORONERS PHYSICIAN OR COUNTY AORNEY
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<br />32. REGISTRAR
<br />.327 Da TE FILED BY aSTRAR Ay p,,,. r.
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<br />_ MAY 15 mm
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