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200306933 <br />WNENTHSCOPYCARRES AE RAISED SEAL OF THE NEBRASKA NEALTHAND HUMAN SERVICES <br />SYSTEM ?CERTFESTIE BELOW TO SEA TRUE COPYOF THE ORIGINAL RECORD-ON FS.E WITH <br />THE NEBRASKA PEALTH AM HUMAN SERVICES SYSTEM. VITAL STAT7SMS SECTIOKINNICHIS <br />THE LEGAL OEPOSITORYFOR VITAL RECORD& <br />DATE Of ISSUANCE COOPER <br />4/155/2003 A$SIETTANTSTAYERVIRISTRAR <br />LINCOLN, NEBRASKA IEALTHAMOIAMNSERVICES MTEM <br />STATE OF NEBRASKA- DEPARTMEM OFNEALTH ANDm16fAN9ERV{OEKPHIANyRA[m 611PPDRT <br />BSUA STAMMS -= 0 3 04096 <br />CERTIFICATE OF DEATH '` °'` <br />I. TIOIDIN, -WAR FIRST MIDDLE 1A6r <br />3Femie. <br />u[ VFDERTH MONO wp ✓xry <br />Rosyln Louise Stepanek <br />April 6 2003 <br />a. Clt✓ AND STATE OF BIRTH / nLLSfi.. rvnwa'wrlyl <br />p"y- <br />AT` <br />yAGELAIMmry <br />a xDEP, VEwP <br />VNDEP, DPY <br />flDAIEOF PIMX 2bin Gay. Ywl <br />Grand Island, Nebraska <br />66 Ea. <br />July_29. 1 -936 <br />- - - - " - -- <br />MDB�' MV9 <br />k. WVR4 MINS. <br />z SOCIMSECUFnV NUMBER <br />Ba pucEOF OfAiX <br />507 -36 -2984 <br />HOSPITAL 7® 1". OTHER ❑ N-RIE m. <br />ANNE R'. <br />❑ EP OWAnI ❑ PxWc. <br />- <br />Fnu,V.N. II hn AA.— ru <br />B u m -I <br />'. Howard County Community Hospita <br />❑ DGP ❑.1.1 xp, <br />Be. 111 . TGNx OF LOCFnoN DF DFATI <br />M INSIDE OFTVUM <br />of DFATX <br />St. Paul, Nebraska <br />II I El <br />Howard <br />PESIDEx VIA" <br />Y�Nebraska <br />'.Ad- <br />is C1LY, i4N110P LOCAipX <br />h,NeH PxO ryuMBEP Iwvna9➢O CUbI <br />RR Ix..I Iry Iu, <br />I� Howard <br />St. Paul <br />949 Hardy Road <br />E.1.9.. wnlm. BU.Y. AmnionlRdYd <br />PNE.N1AY 1.4. HARAN M.ew. GnmA,SE, <br />1D-I <br />,x UYS. -ED ❑WIDOWED <br />NAME OF SVausE 11 H, n D <br />.b l6AMNI White <br />DIVOBEED <br />Eddie Stepanek <br />MABB <br />vfiw - -x lax W .mxa v <br />mx +.A+�P� <br />aHOUSewif <br />.e INDOF1Y161NESSINDUS,m <br />wmx 16AOhe 11 nwn. vLa. ami d <br />ELm.mi.YOre.00-lew lw z� PoIME.L O, s -I <br />w..,g +MIBw <br />Own Home <br />. MIDDW 1ASi <br />11 NAM, <br />FORT wpgE SURNAME <br />Walter T. Olsen <br />iMe-c) Meta GrosehEN <br />WAD DECEASED EVER IN u.fi. <br />19 BRAD <br />. INFORMANT ^ " <br />EStepanek <br />e...MA) I,,MR-YP;".�TAMINS,:.A.,1 <br />Eddie <br />No <br />W,DPMPNr MAIM INC ADDPEas 16TREEr CPa D. ND.. cIrvoBTOwX. srATE.OPI <br />�� 949 Hardy Road St. Paul, NE 68873 <br />�nEA MEP 6 PTUREBODENSE NO 04® <br />METHOD OF DI V <br />WiE <br />FPY DP EMATOPV NME <br />El <br />aNAR, ❑N.mw.I <br />A r 10 200 <br />Elmwood Cemetery <br />NEN NDME.E Jacobsen -WEBY <br />OFCREMATORY LATIN OR DR <br />Greenwav Funeral Home <br />❑Q,in'°'I �°"' "'"" <br />St. Paul Nebraska__ <br />X4NN NOME.. -FRE IS-.-OR B.f D. ND.. SIR US '—A BTPTEZIPI <br />11 O Street St. Paul, NE 68873 _ <br />MMDIATECALSE ENT TER ONLY ON E CAUSE PER LIKE FOR aL I hL ANOIep vNnY bM.e ARAM -MAH <br />�EA <br />PART <br />J E .ON AS A cox,.EGUFrJL DF I IHINAN MRSARAMam acme <br />� wETO. DRJZncoxsEOUENCEDR I.a..,x w.x...ryMI'd A... <br />OTHER yGNIFCAx ONgTION s. coblm„ VRRVI WO,. EAN, wM ea,.awa "._ JnT <br />D <br />BI IF FEMALI WE TOR, A ALDERNEY <br />IRREAD TO SEAL <br />PFEB. <br />uR �dNHL <br />AEY IN THE PAST I MONTHS? <br />Exml OADREUNFRI <br />x�❑ <br />RrLJIU IPVA,h6AT <br />N. <br />- <br />Add DATEOFIwuPV fl Ad:'C YN <br />GID. NOVB US <br />.....ISE HEAVY ALL RV.....EDVA <br />o AI M F-1 L .N,mm <br />El $wnee IJ P aIn <br />EB.. INJUPV Ai WORM <br />3 &..ARSE. LEUfliYMVgJxc'W iN lvme.IVm. »ex.Iwmy <br />G� <br />e•ry'N/ <br />xty. LCCAnOx STREET OR P.ED. NL. CITVOPTOWN STATE <br />Xav-0e I- <br />A ❑ Ib ❑ <br />TE OF TI SAY Poy. YiJ <br />PTE 6MGNED /Ma Mx ✓.J <br />EATX <br />Xo 003 <br />,3 <br />P�� <br />u£' <br />IMOey Ol <br />n. TIME OF DEATH <br />DN <br />.TC WxCED DFAD Ime ay Y.I <br />cfD DEAD rNwl <br />lit <br />i 9- 03 <br />!I.v.ao M <br />z8 <br />na.T mrl„..I.cv.. <br />v.. a <e.l.a� �.N�...m,.,.IIY..ov,w.. ..AMART. M <br />E3 <br />..In Nwa. <br />�. ISO Ad. M... I. a N.I. x..aM.xnna <br />O OUSE LOXTPJBUTET E FA <br />IO10O <br />HAE VHGAx VP TIbbuE DOxP'T Ex COUSmEPED'+TM• <br />p "� <br />\YP6CIXI6BR GPPHTEED <br />YES 0 NO ❑THUNMIgWN <br />❑ YES NV <br />❑ YES ❑ NO <br />J. NPMEPND ADDRESSOF CER,IFIER MPxY61G4x. LORONEPF PxvSICUx OPLOUNIV AnDBNEYI LON, R4NI <br />m o Box -13 <br />c� :5 oEF,1,u0It o - <br />REgbmAP <br />_ <br />1ATIFIL EO BV REGISTRAR /M... Day. 01 <br />APR 14 2003 <br />N <br />