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<br />WHEN p" COPY CARR ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND'HG N SE S
<br />SySTEAg IT CERTIFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REoog" FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEX VITAL STATiS T 011is 4lIICH 1$
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />OF ISSUANCE ,
<br />DATE
<br />JUN 12 2003 2 0 0 3 0 916'7 FIST _ ._GI►R
<br />LINCOLN, NEBRASKA HEALTHAI® HMON SERVICES l*M
<br />STATE tir NEBRASKA l7EPAitTAiMT OF t1EJtC1TE _
<br />SUIEAU OF VITAL STATl�TICS - 91
<br />018, :X-0, 6
<br />OF. 6EAT�-
<br />1: DECEDENT = tMME FIRST MIDDLE LAST 2. an 3.' DATE OF DEATH' /YDI/l Dpt Yaar1
<br />Irene BenJ amin Female : ; " Jul 7 - ::3991.
<br />WAND STATE OF eIRTH rMttaln USA. nrre ooweYl 5a AGE - Ugl3iptlyr: - - x DATEOF._SIRiM- .!Aaotre
<br />IYro.) - ft MOS: DAYS Sc t10NRS1 '
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<br />Cairo, Nebraska 73 ; April 6; 191$
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<br />WHEN p" COPY CARR ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND'HG N SE S
<br />SySTEAg IT CERTIFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REoog" FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEX VITAL STATiS T 011is 4lIICH 1$
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />OF ISSUANCE ,
<br />DATE
<br />JUN 12 2003 2 0 0 3 0 916'7 FIST _ ._GI►R
<br />LINCOLN, NEBRASKA HEALTHAI® HMON SERVICES l*M
<br />STATE tir NEBRASKA l7EPAitTAiMT OF t1EJtC1TE _
<br />SUIEAU OF VITAL STATl�TICS - 91
<br />018, :X-0, 6
<br />OF. 6EAT�-
<br />1: DECEDENT = tMME FIRST MIDDLE LAST 2. an 3.' DATE OF DEATH' /YDI/l Dpt Yaar1
<br />Irene BenJ amin Female : ; " Jul 7 - ::3991.
<br />WAND STATE OF eIRTH rMttaln USA. nrre ooweYl 5a AGE - Ugl3iptlyr: - - x DATEOF._SIRiM- .!Aaotre
<br />IYro.) - ft MOS: DAYS Sc t10NRS1 '
<br />MINS -
<br />Cairo, Nebraska 73 ; April 6; 191$
<br />(:SOCIAL SECURITY NUMBER - ft PLACE OF DEATH - YY - -
<br />.. - HOSPITAL: ql flpaliaa ❑ EWOlspaaae ❑ C,iA -
<br />SQb -26- 9567. .o NwpwHan.- Q R,eldsrlea 0 OMer/Spec*,
<br />ACIUTY -Name (O ter 6rsNefOM1 pis►a►asTend rNSnarl - - !F CITY. TOWN OR LOCATION OF DEATH .t0. 8181Dg CITY LIMITS
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<br />21.' - SKINATURE 6 LICENSE NO. 22 FIHiEgAL 110AAE -NAME AND ADDRESS R F.D. ND. 6RY OP1 TOWN STATE 2tP) 6Q8v ,
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<br />OR PENDING INVESTIGATION ($pWffyj - .. - - • .. - - • . - . _..: r :. .: -- . .'. ,.:
<br />-. -INJURY AT WORK 2K PLACE OF INJURY - At home. farm atOet. hebry. 2%. LOCATION STREET OR R.F.D. NO. • .. � CITY OR TOWN - - � STATE
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