|
0 1 VIE A SKRW r-M I C" IWL*4S - Cv Ma Cwk%V" 111* dP• W FO I M IT TV MALE, WK4t I MkFe Attlopsy 2S WASCARMFONFIEDIC
<br />►Ant
<br />id $490 '11-341 via
<br />yap P elu4z- "A n
<br />Ift N)Aff or *&ART two. nor TV) 12ft "OLIP10: *uuF*f m at HUNFURIMUCCUP11111(l)
<br />❑ A,,M�o ❑ Im - im
<br />❑ r,*,%% ❑ P- %.q fp• kRiw Al WOW 1 26 =L%qAffly g=4 ft OW MM. Nq tOrAWN Ply on 10*0
<br />L] I,-*Of I A I Y. ❑ 'm 0 wc
<br />TI MKAHDAMf*SS0FCERIffWRrW=
<br />Roland Mo
<br />FOR VITAL STATISTICS USE ONLY
<br />Place ........_ .........R,,.........__._.....- - ,B. . ................
<br />............. . .....
<br />Work.......__._ ..............
<br />Reject.
<br />I• JAIJ 20*0 PAV OW Wt M 10%OPMA104
<br />2,"T
<br />• Tits OF" on Immm Q"lv" 114[tow COMM""* -vb VMS CONSENT 1~11far
<br />11 m, K
<br />(lRC011MTVATT0181ET1
<br />05 NE Ave. .L-Box 437. Ara2ahoe, Ne 68922
<br />3ft CAVE n"ST rEp9IMPA Owe, vw-
<br />OPT, ---- - —6
<br />I
<br />11 ----TMV
<br />Traci No.
<br />0,1
<br />Farmer
<br />A9riculture
<br />lu
<br />$it FAJ.IEF'.•AW FOIST
<br />110ANXII SUPIDIAIM
<br />k e Jacobs
<br />7
<br />Nemir
<br />4
<br />n
<br />.
<br />41
<br />Esther Jacobs
<br />ACV. 1194
<br />STATE OF NEB"ASXA L ip.A'ftfmEml, VF MALI"
<br />BUREAU ov VITAL STATISTICS
<br />9 6 1V2•
<br />1�M YM1,11q AOQAE"� tSII*EI OFINVO TOWN SIATIE M.
<br />7
<br />CERTIFICATE OF DEATH
<br />TIM-
<br />101=11
<br />2 2"
<br />x
<br />3 call w MITI. Oft-401 zw row -
<br />John Har Jacobs
<br />Ex
<br />Male
<br />January 29,, 1995
<br />14 CHYANUSIA1110FW" fg-W"U.14 �CWO,
<br />tpcmlvtm
<br />umelt I
<br />DAY
<br />a DATE OF VWM X;W% am V084
<br />SIAIE
<br />Gothenburq Nebraska
<br />.82
<br />OATS.
<br />x mum:
<br />May .29r 1912
<br />A el Funeral Home
<br />T. SQCV4 Xofflvm HLWAK"
<br />a PLSAMOF NAM
<br />9 r1 �-L- 0
<br />508-10-2213
<br />u�
<br />W �00 Riv 8883-126
<br />er NE. 6
<br />0
<br />C
<br />w VI
<br />73 f0AE(XAIECAt)%f KNINTRUNLY umecmse KatoqE 6QR to *LAM"
<br />P AW,
<br />I v/0 C d1T
<br />0
<br />Walker post Manor
<br />OL* IQ 00 AS A COMSFVUEMCE OF
<br />III* 0-ah
<br />0"llf OF NAM
<br />oxford
<br />Furnad'
<br />ZW96JRct7sIAff
<br />tcpi"tv
<br />it City 100HORLOCAt"
<br />11• gas" OR E-15
<br />Nebraska
<br />Hall
<br />1Wood River
<br />1002
<br />Cottonwood 60683
<br />V-9 - 1:1
<br />L4,
<br />00-0%ditt
<br />• VAPME111 ❑
<br />03 IVAROF spom woo* vw-060-W4
<br />mmft#0
<br />White
<br />MOM40 Lebanese
<br />El '" 0100011014)
<br />F wmwa---DmPm"
<br />Bother Wilcox
<br />mo usu'XMICIPAI"
<br />at wo-vw ~11061101
<br />9MMAIMN
<br />0"mme 411481 C~ to .4 40 91-1
<br />0 1 VIE A SKRW r-M I C" IWL*4S - Cv Ma Cwk%V" 111* dP• W FO I M IT TV MALE, WK4t I MkFe Attlopsy 2S WASCARMFONFIEDIC
<br />►Ant
<br />id $490 '11-341 via
<br />yap P elu4z- "A n
<br />Ift N)Aff or *&ART two. nor TV) 12ft "OLIP10: *uuF*f m at HUNFURIMUCCUP11111(l)
<br />❑ A,,M�o ❑ Im - im
<br />❑ r,*,%% ❑ P- %.q fp• kRiw Al WOW 1 26 =L%qAffly g=4 ft OW MM. Nq tOrAWN Ply on 10*0
<br />L] I,-*Of I A I Y. ❑ 'm 0 wc
<br />TI MKAHDAMf*SS0FCERIffWRrW=
<br />Roland Mo
<br />FOR VITAL STATISTICS USE ONLY
<br />Place ........_ .........R,,.........__._.....- - ,B. . ................
<br />............. . .....
<br />Work.......__._ ..............
<br />Reject.
<br />I• JAIJ 20*0 PAV OW Wt M 10%OPMA104
<br />2,"T
<br />• Tits OF" on Immm Q"lv" 114[tow COMM""* -vb VMS CONSENT 1~11far
<br />11 m, K
<br />(lRC011MTVATT0181ET1
<br />05 NE Ave. .L-Box 437. Ara2ahoe, Ne 68922
<br />3ft CAVE n"ST rEp9IMPA Owe, vw-
<br />OPT, ---- - —6
<br />I
<br />11 ----TMV
<br />Traci No.
<br />0,1
<br />Farmer
<br />A9riculture
<br />lu
<br />$it FAJ.IEF'.•AW FOIST
<br />110ANXII SUPIDIAIM
<br />k e Jacobs
<br />Helen
<br />Nemir
<br />Esther Jacobs
<br />1�M YM1,11q AOQAE"� tSII*EI OFINVO TOWN SIATIE M.
<br />7
<br />x
<br />1 02Cottanwood Wood River, NE. 68883
<br />IE**A4,Wn •SKWAIUFW 4 t"WA II0
<br />CATE
<br />2ft NAAAE
<br />Peb 3, 1995
<br />Shelton CemeteEX
<br />tu�jemjj HAAME
<br />SIAIE
<br />1�
<br />a
<br />w
<br />DD ---- El a,~F,..
<br />A el Funeral Home
<br />Shelton NE
<br />770 f1)H$Lr-,A -ow uuAESS r3lFW�10ITF4FOM0 C11TORIOWS1AILZIPT
<br />u�
<br />W �00 Riv 8883-126
<br />er NE. 6
<br />C
<br />w VI
<br />73 f0AE(XAIECAt)%f KNINTRUNLY umecmse KatoqE 6QR to *LAM"
<br />P AW,
<br />I v/0 C d1T
<br />DUE 10, On AS A CQWAQk$EfJU OF
<br />OL* IQ 00 AS A COMSFVUEMCE OF
<br />III* 0-ah
<br />0 1 VIE A SKRW r-M I C" IWL*4S - Cv Ma Cwk%V" 111* dP• W FO I M IT TV MALE, WK4t I MkFe Attlopsy 2S WASCARMFONFIEDIC
<br />►Ant
<br />id $490 '11-341 via
<br />yap P elu4z- "A n
<br />Ift N)Aff or *&ART two. nor TV) 12ft "OLIP10: *uuF*f m at HUNFURIMUCCUP11111(l)
<br />❑ A,,M�o ❑ Im - im
<br />❑ r,*,%% ❑ P- %.q fp• kRiw Al WOW 1 26 =L%qAffly g=4 ft OW MM. Nq tOrAWN Ply on 10*0
<br />L] I,-*Of I A I Y. ❑ 'm 0 wc
<br />TI MKAHDAMf*SS0FCERIffWRrW=
<br />Roland Mo
<br />FOR VITAL STATISTICS USE ONLY
<br />Place ........_ .........R,,.........__._.....- - ,B. . ................
<br />............. . .....
<br />Work.......__._ ..............
<br />Reject.
<br />I• JAIJ 20*0 PAV OW Wt M 10%OPMA104
<br />2,"T
<br />• Tits OF" on Immm Q"lv" 114[tow COMM""* -vb VMS CONSENT 1~11far
<br />11 m, K
<br />(lRC011MTVATT0181ET1
<br />05 NE Ave. .L-Box 437. Ara2ahoe, Ne 68922
<br />3ft CAVE n"ST rEp9IMPA Owe, vw-
<br />OPT, ---- - —6
<br />I
<br />11 ----TMV
<br />Traci No.
<br />0,1
<br />
|