|
M?iEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN $ERVI
<br />CL
<br />SYSTEM, RCERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON_8LE, ;
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTI -_'JS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />Aie- " ::
<br />DATE OF ISSUANCE
<br />DEC 1 5 2004 A
<br />NL -EYS; COv1 -
<br />2 0 0 412 2 5 8 SS/81AM£iiT/�RAR
<br />LINCOLN, NEBRASKA HEALTHANDt1 N 1�
<br />I-
<br />STATE OF NW-AMA - DWA RI%Mff OF HEAL IM AND Ht bjM 3WvIC$4 ANCK Al 311PPONt
<br />MAIL STATiS7](.`S , g g 09644
<br />CERTIFICATE OF DEATH ` -
<br />1. DEMOUNT .1NeLE s9sar IRaOtL LAST .'�._ —. ('�, sEx a. aiTt oc ouTN e0 .wt. a.r. rri
<br />r. an AHe srA7T ac I9PTH - N ttev a v.Jj A., RM1.a11.RFV , 9n AGE - "o INN en T Y _S ?Wjpkx DATE of wTTt AbRlt Aw. ww
<br />Y� r"i it Tens onus sc. Nows � V
<br />I�Cam �ooa TOM - - - - - -- 65 1 I Mg 17,1933
<br />7. SOCIAL SECAIR1TTt 111110111611 iW PIACE OF DEATH
<br />5046&I9W7 _ I . � IA?WNtR am �Eq] N d.0 N.-
<br />a. rACKM - NNRt AV R« rneftli R.,A. e24W wda.Renr/ ❑ ER OvlSM&W
<br />1 1109 Harrison St. ❑ Ix7A ❑ D.R. vr.ue __ ___ _ _. _ -. _._ _ -_ --
<br />%. CITV, TOWN OR LDwTION OF 06ATO -� w. am city Loma "_ "Ha"TY OF DEATH - - -- - - - -_
<br />Wood River Y« ® NO Hall
<br />w. IEEIOSNDT.- WAVE s. Could" ift. CITY, TONN /M LOCATION w. aTREET AND MReRRR AWWOA„ CSOW - — i s. iLl1eE tui sNiet
<br />I
<br />Nebraska Hail ___ Lwood River 1109 Ha_rrisas SL 66iL3
<br />,v.A - 604.. INK*.. ««.. JM.I,, ftmom, .11. AeEOIsTRW.. I... LL1...; 4..:. «�t ,2 E�ARI�D WIDDW®D Ly. «e.EF >:," . r NIv V ".3111p dig!
<br />wh;*. ! Lii.R !A MHEwn r 1OIVORLED Wes— r--
<br />14e.11SIIAL000UPMI10N 16VV�AEvftMvice.LRrRtnift- -C)'41 trb.AMOF eeDUSTRY g�
<br />W IVr *OrR S A dv.v IT .0 —
<br />!I /t. F.ATNER -YArAF F1efST NpDiE 1�A ___ JuII
<br />+L'T T,. MO 7f1ER FAST
<br />F FO MASFACEACF— %"14U$ AIWIFOFORCLST— Iw
<br />TalCOA OANT.NNAF
<br />IE
<br />!V«, t. P 1Nd -i '. IR vRt• � vM rIrY.F d rntttl
<br />_ ___ Hector Faz
<br />191, ftROeMANT NIARIWS ADDRESS LSTRLET OR R F.D. NO.. CITY OR TOWN. STATE. LPI _ —' - --
<br />1u9 Harrison St. Wood River NE. 68883
<br />_ - - -- - -� 21 0 ov DISPOSITION 21e. OATE — 2T� aeeETpv w aIWrTOR/ NFtR - _ _. _ _
<br />.o. Lxx wE
<br />_ _ _ --_ -- _,.� ®a.I. ❑RNIRwaI �08/26l19�$ _� Wooded tiiyer_C�O�C[]t- _- _ -- - _
<br />2 - 121d. CEMETERY OR CREMATORY ltiGlWN tiiY AIR 10WN t1ATL
<br />—
<br />A�fel_Funerat Home _ i F-j IA.tt.eee ooe.wn ! VI/OOd River, Nebraska
<br />- Za.I "UNERAL IR7AM: AOIMNTS WIN"T OAF R.F.D. NO.. arY OR TOWN. STATE. VIP!
<br />_Wood Riv-er,NE�6$883 - _._-- -___ --
<br />23 11" MATE CAW aNnit nim ow GusE PER LINE we w, ow, AND soil -• -- - .y.- - - - -i._ _. —I...r o�...�....t .r...� -
<br />IY1AJ
<br />- �- Multi -►t em.i�ure - -- - -- -- - -iD dada -- - --
<br />1" 10 OR AS A 0061901.096TS of
<br />I
<br />�aiishea e�s7�t nBte �_ callbladder CA - -- . - - - - -- - - -- -- - 11 months- -
<br />IJIIF TO tHt AS A CON OF Wave vetve„n eeR. wt U.A
<br />DINER SK/YFH',ANT CONp17gNS. CCedtirw eegrgrtYq to ty dt.e 6. eat t,M,d PART IV IF FUMAIE WA'1711ENE0. 24. AUTOFl1Y 2tr. WAS GS'k IIFEMLO TO MEDICAL
<br />PANT PRCGNANCV N TNF PAST 3 MONTHS? — ExAMNER ON CORIxEA?
<br />R ASCYD d COPD �Uo:! ledil —_ Y« -- "-« F. i .. .� ?..�t__
<br />lie — 7A GATE Ci OdJURY Jdly, OeA 1,7T 0c. HOUR OF WURY 20d OESCRIK HOW NA7RY OCrUHMD
<br />t C❑ A.dd.. IN.R.te..d N/A _ M
<br />i 0nrfdv LJ FyeAy �. NdUNY AT WORK 20. HACF OF INJURY At Inn., Ins. «en, f".v 209. LOCATION SINES I ON R F.O NO _ =v Url IO WN STATE' - - -_
<br />eT11eTNledl etc. v- - - - -�-
<br />.. Nan.mv e�tntttleL.n ' Y« ,
<br />--�' —. -- . - -_.y. — iii. 20e. DATE 31GNF0 fMO. DeY. Y.J r 20b IY! �F UFArN
<br />i 27e OATF OF UEATN UAo. MP. Yrl
<br />August 23 ] 998 I d
<br />t L - -_ __ _S_._..
<br />_ ,'� ' 27b. DATE SKiNLU TMe, (i,y, K J —r27o. THE OF fikAM � �- 2&.. rNOHOUNCLD DCM OYe:Op. Yr.i —r7Nt J-A'nlOJenI,TJ +AC' INw..
<br />t + Au Lost 26 , 1998
<br />...'" --
<br />E 4a5 27d. '.e IM Wt d n fu tM.,d.e t.d place �T 1`rN» to tin � � 2(a. On tM ttRr of eultwlive renbt tnva -y,e�. , ,r� n. r.+Pl.r,n 4ue �, eec.n0 n<
<br />A I A A i A t A i \ ! ` th tYns. d.e end tdeu .d dw le tht c+twl.l na N
<br />20. CRT TOAAr.rO USL /:CNtfdeU/E ? OE T 30e. HAS O ON TK ;U C Wf;TNN BEEN COe1510FRE07 - --
<br />^'
<br />NO uNKNOwN r� rE.., No _ �. No '
<br />_. nn
<br />at NAME AND Ai7OT4S5 Of CTRIaIEN IPIIY:ACIAII, CORONERS PItYSICJAN OR COUHri A fTI7RNEY1 / /rps n Anrl �
<br />-1- -Steven L. Husen, M.D., 2J16 W. Faillep #1400, Grand Island, NE 68803 j
<br />_.. _ - - - - ----
<br />— - --
<br />S.P. REGISTRAR aae DATE _ -. FxE_ D - ev - RE-- -OI- ST- -- RJ-M - JNr. JJxe. rt.,
<br />1 �
<br />LEGAL- The Fouth Half or
<br />Lots . c
<br />even (7) Finht (8) and dine (0), in Block
<br />Twelve (12) in Frett and Johnson's Addition to t1le "illaae of Wood River,
<br />Fall County, Nehraska
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<br />M?iEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN $ERVI
<br />CL
<br />SYSTEM, RCERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON_8LE, ;
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTI -_'JS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />Aie- " ::
<br />DATE OF ISSUANCE
<br />DEC 1 5 2004 A
<br />NL -EYS; COv1 -
<br />2 0 0 412 2 5 8 SS/81AM£iiT/�RAR
<br />LINCOLN, NEBRASKA HEALTHANDt1 N 1�
<br />I-
<br />STATE OF NW-AMA - DWA RI%Mff OF HEAL IM AND Ht bjM 3WvIC$4 ANCK Al 311PPONt
<br />MAIL STATiS7](.`S , g g 09644
<br />CERTIFICATE OF DEATH ` -
<br />1. DEMOUNT .1NeLE s9sar IRaOtL LAST .'�._ —. ('�, sEx a. aiTt oc ouTN e0 .wt. a.r. rri
<br />r. an AHe srA7T ac I9PTH - N ttev a v.Jj A., RM1.a11.RFV , 9n AGE - "o INN en T Y _S ?Wjpkx DATE of wTTt AbRlt Aw. ww
<br />Y� r"i it Tens onus sc. Nows � V
<br />I�Cam �ooa TOM - - - - - -- 65 1 I Mg 17,1933
<br />7. SOCIAL SECAIR1TTt 111110111611 iW PIACE OF DEATH
<br />5046&I9W7 _ I . � IA?WNtR am �Eq] N d.0 N.-
<br />a. rACKM - NNRt AV R« rneftli R.,A. e24W wda.Renr/ ❑ ER OvlSM&W
<br />1 1109 Harrison St. ❑ Ix7A ❑ D.R. vr.ue __ ___ _ _. _ -. _._ _ -_ --
<br />%. CITV, TOWN OR LDwTION OF 06ATO -� w. am city Loma "_ "Ha"TY OF DEATH - - -- - - - -_
<br />Wood River Y« ® NO Hall
<br />w. IEEIOSNDT.- WAVE s. Could" ift. CITY, TONN /M LOCATION w. aTREET AND MReRRR AWWOA„ CSOW - — i s. iLl1eE tui sNiet
<br />I
<br />Nebraska Hail ___ Lwood River 1109 Ha_rrisas SL 66iL3
<br />,v.A - 604.. INK*.. ««.. JM.I,, ftmom, .11. AeEOIsTRW.. I... LL1...; 4..:. «�t ,2 E�ARI�D WIDDW®D Ly. «e.EF >:," . r NIv V ".3111p dig!
<br />wh;*. ! Lii.R !A MHEwn r 1OIVORLED Wes— r--
<br />14e.11SIIAL000UPMI10N 16VV�AEvftMvice.LRrRtnift- -C)'41 trb.AMOF eeDUSTRY g�
<br />W IVr *OrR S A dv.v IT .0 —
<br />!I /t. F.ATNER -YArAF F1efST NpDiE 1�A ___ JuII
<br />+L'T T,. MO 7f1ER FAST
<br />F FO MASFACEACF— %"14U$ AIWIFOFORCLST— Iw
<br />TalCOA OANT.NNAF
<br />IE
<br />!V«, t. P 1Nd -i '. IR vRt• � vM rIrY.F d rntttl
<br />_ ___ Hector Faz
<br />191, ftROeMANT NIARIWS ADDRESS LSTRLET OR R F.D. NO.. CITY OR TOWN. STATE. LPI _ —' - --
<br />1u9 Harrison St. Wood River NE. 68883
<br />_ - - -- - -� 21 0 ov DISPOSITION 21e. OATE — 2T� aeeETpv w aIWrTOR/ NFtR - _ _. _ _
<br />.o. Lxx wE
<br />_ _ _ --_ -- _,.� ®a.I. ❑RNIRwaI �08/26l19�$ _� Wooded tiiyer_C�O�C[]t- _- _ -- - _
<br />2 - 121d. CEMETERY OR CREMATORY ltiGlWN tiiY AIR 10WN t1ATL
<br />—
<br />A�fel_Funerat Home _ i F-j IA.tt.eee ooe.wn ! VI/OOd River, Nebraska
<br />- Za.I "UNERAL IR7AM: AOIMNTS WIN"T OAF R.F.D. NO.. arY OR TOWN. STATE. VIP!
<br />_Wood Riv-er,NE�6$883 - _._-- -___ --
<br />23 11" MATE CAW aNnit nim ow GusE PER LINE we w, ow, AND soil -• -- - .y.- - - - -i._ _. —I...r o�...�....t .r...� -
<br />IY1AJ
<br />- �- Multi -►t em.i�ure - -- - -- -- - -iD dada -- - --
<br />1" 10 OR AS A 0061901.096TS of
<br />I
<br />�aiishea e�s7�t nBte �_ callbladder CA - -- . - - - - -- - - -- -- - 11 months- -
<br />IJIIF TO tHt AS A CON OF Wave vetve„n eeR. wt U.A
<br />DINER SK/YFH',ANT CONp17gNS. CCedtirw eegrgrtYq to ty dt.e 6. eat t,M,d PART IV IF FUMAIE WA'1711ENE0. 24. AUTOFl1Y 2tr. WAS GS'k IIFEMLO TO MEDICAL
<br />PANT PRCGNANCV N TNF PAST 3 MONTHS? — ExAMNER ON CORIxEA?
<br />R ASCYD d COPD �Uo:! ledil —_ Y« -- "-« F. i .. .� ?..�t__
<br />lie — 7A GATE Ci OdJURY Jdly, OeA 1,7T 0c. HOUR OF WURY 20d OESCRIK HOW NA7RY OCrUHMD
<br />t C❑ A.dd.. IN.R.te..d N/A _ M
<br />i 0nrfdv LJ FyeAy �. NdUNY AT WORK 20. HACF OF INJURY At Inn., Ins. «en, f".v 209. LOCATION SINES I ON R F.O NO _ =v Url IO WN STATE' - - -_
<br />eT11eTNledl etc. v- - - - -�-
<br />.. Nan.mv e�tntttleL.n ' Y« ,
<br />--�' —. -- . - -_.y. — iii. 20e. DATE 31GNF0 fMO. DeY. Y.J r 20b IY! �F UFArN
<br />i 27e OATF OF UEATN UAo. MP. Yrl
<br />August 23 ] 998 I d
<br />t L - -_ __ _S_._..
<br />_ ,'� ' 27b. DATE SKiNLU TMe, (i,y, K J —r27o. THE OF fikAM � �- 2&.. rNOHOUNCLD DCM OYe:Op. Yr.i —r7Nt J-A'nlOJenI,TJ +AC' INw..
<br />t + Au Lost 26 , 1998
<br />...'" --
<br />E 4a5 27d. '.e IM Wt d n fu tM.,d.e t.d place �T 1`rN» to tin � � 2(a. On tM ttRr of eultwlive renbt tnva -y,e�. , ,r� n. r.+Pl.r,n 4ue �, eec.n0 n<
<br />A I A A i A t A i \ ! ` th tYns. d.e end tdeu .d dw le tht c+twl.l na N
<br />20. CRT TOAAr.rO USL /:CNtfdeU/E ? OE T 30e. HAS O ON TK ;U C Wf;TNN BEEN COe1510FRE07 - --
<br />^'
<br />NO uNKNOwN r� rE.., No _ �. No '
<br />_. nn
<br />at NAME AND Ai7OT4S5 Of CTRIaIEN IPIIY:ACIAII, CORONERS PItYSICJAN OR COUHri A fTI7RNEY1 / /rps n Anrl �
<br />-1- -Steven L. Husen, M.D., 2J16 W. Faillep #1400, Grand Island, NE 68803 j
<br />_.. _ - - - - ----
<br />— - --
<br />S.P. REGISTRAR aae DATE _ -. FxE_ D - ev - RE-- -OI- ST- -- RJ-M - JNr. JJxe. rt.,
<br />1 �
<br />LEGAL- The Fouth Half or
<br />Lots . c
<br />even (7) Finht (8) and dine (0), in Block
<br />Twelve (12) in Frett and Johnson's Addition to t1le "illaae of Wood River,
<br />Fall County, Nehraska
<br />
|