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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTE6RK R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORD& / A <br />DATE OF ISSUANCE <br />8/8/2003 ANLEY & COOPER <br />ASSISTANT STATE REGISTRAR <br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM <br />STATE OF NEBRASKA- DEPARTIG NT OF HEALTH AND H[IMAN SUVXM FQIANM AND SUPPORT <br />VITAL STATISTK3 <br />CERTIFICATE OF DEATH 03 <br />20041o920 <br />• <br />` DECEDENT - rY1ME FIRST LLODLE LAST <br />2. SEX <br />1 DATE OF DEATH /WN-0 DAY YaW <br />Elois Leon Nichols <br />Female <br />July 31 2003 <br />4 CrTV ANO STATE OF BWTH .,,crw USA. n CdwWY/ <br />Sa AGE -Lam 0W.W <br />LOOM I YEAR <br />MOM I DAY <br />a DATE OF BOTH AAWWR Div YWK1 <br />. <br />Sb MDt art <br />. <br />x -mm <br />rl Aga.. L111oa1......a <br />(YK►I <br />Belgrade, Nebraska <br />79 <br />' <br />M <br />March 9 1924 <br />r SOCIAL SECUFMY NUMBER <br />4 PLACE as DEATH <br />"0� ® ❑ Nanap K10n1a <br />506-28-2785 <br />24 LOCATION STREET OR RF D. NO CITY OR TOWN STATE <br />❑ Ep O111oanKa ❑ RaaaNttce <br />ft FACILITY - true Ie.Nwasm pve~&V rnaMM <br />St. Francis Medical Center <br />❑ DOA ❑ Dow4wft' - <br />_... <br />,� CIT. TO1NN OR LOCATION OF OEATH N WWOE CRY (WITS <br />as COUNTY OF DEATH <br />Grand Island I V. F11 Na ❑ <br />Hall <br />9a RE SNDCNa. ST ATE fb COUNTY <br />ft. CITY. TOWN OR LOCATION <br />M STEETAN "No 1ft%ft F4i10.C4CW Ir &4" CM LAATS <br />Nebraska Hall <br />Grand island <br />428 Z. Nebraska 68801 Yea FL Na <br />�Q RACE Na.'Mw 81AC• &r wwl WW— <br />I1. ANCESTRY N 0.1Wiw Mae—, D'"n aKtl <br />12 ®MA/PRO ri woomD <br />N. NAME OP SPOLM 0-0 p -meon 14~ <br />white <br />Apes'"' American <br />" " olvaRCEO <br />Neil C. Nichols <br />+AA :J$UAL DCCUPATION .(sw+Wd.n+ ►dn►Anly .nll <br />IM "0 Or susp wINOUSTRY <br />19 EOt10ATIDN <br />1SWCMOMq <br />EY.tarFI a SacvltlarY 10.121 Colapr it.a 5•: <br />TV . —v At er nsm-w <br />Ce1KM1.1 stead. <br />Homemaker <br />Orin Home <br />8 <br />16 FAT.CR.I FPST MIDDLE ,LAST <br />17 MOTHER NiST MIDDLE MAIDEN SUWIAW <br />Arthur Arron McCurdy 1 <br />Blanche Leon Goodman _ <br />to *AS DECEASED EVER N o S ARMED FORCES'! <br />ifa 0*0ft 76T - NAME <br />nNo aa •tn o vtaj I h Yea f,na .a/ KYM ouaa d aanrtcaN <br />Neil C. .Nichols <br />428 E. Nebraska, Grand Island, Nebraska 68801 <br />20 EA SI L i� 21a LaTNCD OF O:F06R10N 21b DATE 214 CEMETFAY OR CREMATORY N" <br />#1071 <br />August ®a1.t1 [� Aorftw l 4e 20Q3 wasttan Memorial Park <br />td+ERA . OME ALE � rd CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE - -. <br />All Faiths Funeral Home ❑C"""°" ❑00~ Grand Island, Nebraska <br />21D FUNERAL NOME ADDRESS (STREET OR 61 0 NO CRY OR TOANi. STATE M <br />2929 S. Locust St., Grand Island, Nebraska 68801 <br />21 AAMEDMTE CAUSE (ENTER ONLY ONE CAUSE PER L** FOR IA1. !L AND Idl - aaar.,l baaaaaw anaKR a naaK• <br />PAR r u j� v i Z nyJ. <br />DUE TO. OR AS A CON6EDUENCE OF ' bow"" awl uYl nr.m <br />.a <br />DUE TO. OR AS A CONSEOUENCE OF Ya.vY beftwen a <br />OTHER S"41FICANT CONDITIONS Cvaevta cartlurq tl KM daa/1 W Rot relalad PART <br />111 IF FEIMLE WAS THEM <br />N AUTOPSY 2L WAS CASE REFB1gE0 TO MEDKCAL <br />.ART PREGNANCY <br />IN THE PAST MONTWT <br />Ex"INER OA CORONER( <br />/7WJ►' • GVAAO)Ai L cL11I'gAla <br />00M10•SJ rM LJ Na <br />rr 7J - Y- F I No FIQ _._.. 19 1 <br />:6a <br />26o DATE fLA/RY AAa DAY. W4 <br />26c. HOUR OF PLILWY <br />2f0. OESCRIBE NOW iL.AlPY OCCWIED <br />rl Aga.. L111oa1......a <br />LJ <br />M <br />_) S..ata. P. y <br />266 *"JRY AT WORK( <br />2a2;4JURY - N No ». W1a VMA YtbY <br />24 LOCATION STREET OR RF D. NO CITY OR TOWN STATE <br />130 <br />SW <br />i 27a DATE OF DEATH 440 DAY Yc/ <br />TEL DATE SIGNED (M0.. Ct, ro <br />2Eb TWE OF DEATH <br />July 31, 2003 <br />27b GATE STONED Ado Ow Y, I 27C TWE OF DEATH <br />24 PRONDUHM DEAD #A* DW n./ <br />286 PRONOUNCED OEAO 0*-, <br />Z S �Jyj 9 A. <br />:06 M <br />s� <br />M <br />i 27. To ti b" d twY Nto.Mape aaaaK occvrae Y He hnw a" And pate aM am O N <br />Zia On ow bows of a wrabn woof M80980M Kn aq ob..on dos" ticcurKae r <br />Ce1KM1.1 stead. <br />a <br />OW 6ta1p.,dM sad PWa Wid QN ID Ens CUMON MMS& <br />t and TOW -- <br />W <br />3 DECO TOBACCO USE CONTRIBUTE TO THE OEATH7 <br />7DA HAS ORGAN OR TISSUE DONATION SEEN <br />COMSIDEREDT <br />70b WAS CONSENT GRANTEO' <br />❑ YES No ❑ UNKNOWN <br />. ❑ YES <br />Z. <br />J <br />❑ YES 1/V NO <br />Jt ~ALIT ANU NJVC�Jt .lt.twr�� +rnry�.wl.t.aJ�aJ�v�n rn�Jw.Yw t.�l,uwYrT wlrl�rwcl/ rrlpv�+.v <br />Anne X. Morse M.D., 729 Y. Custer Ape., Grand Is <br />32a -1ECsSTRAR r't 32b <br />I, Daniel D. Naranjo, do here by certify that this a true and accurate <br />copy f d th ce ficate that is on file with the State of Nebraska. <br />- -' - -- -- -- - -- - -- - - - -- <br />Daniel D. Naranjo <br />