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LEGAL: Lot 2, Block 1, Colonial Estates Tenth Subdivision to the City of
<br />.Ira.. -' I31an 1, -11 ''ounty,
<br />*FEN TM COPY CANINES THE RAISED SEAL OF THE NEBRASKA FAEALTT l AN Ei
<br />SYSTEM, IT (ERT1�S T1E BELOW TO BE A TRUE COPY OF THE ORIGINAL RE
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS, IQN,W#I►CH /S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ss
<br />DATE OF ISSUANCE r
<br />JUL 16 2003 200309219 E''i
<br />ASST -- - . I ,. � ?
<br />LINCOLN, NEBRASKA HEALTH AND
<br />STATEOFN®RAS[A'DEPAR7LI WOF HEAL= AteIRIMANSERVXM 7 �AN�{L1PPOg
<br />VITAL CERTIF[CATF- nV FATU '' t l'F i� 1 A R n 1
<br />t. DECEDENT -NAM FIRST MIDDLE LAST
<br />2 SEk 3. DATE .7F DEATH :AbrYA DAY
<br />Raymond Richard Badsteen
<br />PC
<br />=
<br />Sa AGE - Lm OMfty
<br />I UNDER 1 YEAR
<br />UNDER / DAY 6. DATE OF BIRTH Monf Day Ysffl
<br />5b MOS F DAYS
<br />Franklin County, Nebraska
<br />" "175
<br />5,-"OURS ANN9 gust 19,'1925
<br />7. SOCIAL SECURTIY %UMBER
<br />M
<br />D`
<br />HDSVrtu ❑ M1p88wI OTHER ❑ N..T H1.
<br />❑ ERoIp4wM Res
<br />Be FACILRY -Nw1I. IalY7YM1AIw19Y»aMwwNnu+Mw/
<br />Home: 3107 Magnolia Court
<br />❑ DOA ❑ DOW Slwd-.
<br />st. Cm. TOWN OR LOCATION OF DEATH ea INSIDE CRY UM1TS se COUNTY OF DEATH -
<br />Grand Island I Y. ®No ❑ Hall
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<br />Bo STREET AND NUMW R 10w9j*VZw Caael i 9e INSIDE CRY LIMITS
<br />Nebraska Hall
<br />Grand Island
<br />3107 Magnolia Court 68803Y.a ®,� ❑
<br />M
<br />/3 N�AtM�E�OFSPOUSE rp w#s pwmM7en nArnF/
<br />afe.l lCre161ye ISwcNyl American NEVER DIVORCED
<br />Caroline Adam
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<br />7C
<br />16. FAT14ER -NAAR FIRST MIDDLE LAST MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />William Bftdste F en E=ia Leahy
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<br />3107 Magnolia Court, Grand Island, NE. 68803
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<br />❑`'°'""°' ❑ Grand Island, NE.
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<br />DUE TO. OR AS A CONSEQUENCE N - :�Ie -�'a: be!t.!1r� onsat roc oeav
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<br />OTHER SIGNIFICANT CONDITIONS - C0110 c C lrft Oep n ow dulh blp,0 mylec 1 PARE w IF FEMALE WAS THERE A 2a AU -0ps, 25 WW-.5 ---SE RE
<br />PART .SE FERRED TO WW.AL
<br />PREGNANCY IN THE PAST 3 14ONTH$ 7
<br />cam-
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<br />❑ Sl do ❑ Pak" 25e INJURY AT WORK ;261 a OF CRY %!V Ir.m steel, IaCby [269 LOCATION STREETORRFO NO 'DTY CR TOWN
<br />SAeC STAGE
<br />❑ Y+aA11GOa I Y. ❑ NO ❑
<br />I
<br />278. DATE OF DEATH NO Dar Y%! _- –'-
<br />I j 280 DATE SIGNlD ,AA, (�•. �. , ! itiC 11MR. LYF DEATH
<br />+QQ ^^
<br />27b. DATE SIGNED rMa DIY 1, - 2% THE OF DEATH - -� 8 12& UNCED DEAj As+ Pay. r,Y 2M Pp�YNU1p+C:E; -, D'cAp ,r — M
<br />M i Ss
<br />270 To IlebNld my Oad1 wrxa Nr+K! ewe A,c 01we am mm n C1e _ 28e O, the trills d e.a..m Ira 7. ++ws►gww.. :1,rrr vs a�.r,wT e
<br />Cw1l8I3) a18Y0. - t11e :ne awe wa ty c. n„+! M1,e w pw ca:Ae e, $106C �
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<br />❑ YES E] NO ❑ YES!.! ❑ +E5 I� r
<br />31 PAW AND ADDRESS OF CERTIFIER MMY31C1Ah CORONEM S PHYSICIAN DR COUNTY ATTORNEY —'-
<br />�Sitki CopuS M.D. t 2115 W- Faidley Ave , grand Island NE. €8W3
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<br />LEGAL: Lot 2, Block 1, Colonial Estates Tenth Subdivision to the City of
<br />.Ira.. -' I31an 1, -11 ''ounty,
<br />*FEN TM COPY CANINES THE RAISED SEAL OF THE NEBRASKA FAEALTT l AN Ei
<br />SYSTEM, IT (ERT1�S T1E BELOW TO BE A TRUE COPY OF THE ORIGINAL RE
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS, IQN,W#I►CH /S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ss
<br />DATE OF ISSUANCE r
<br />JUL 16 2003 200309219 E''i
<br />ASST -- - . I ,. � ?
<br />LINCOLN, NEBRASKA HEALTH AND
<br />STATEOFN®RAS[A'DEPAR7LI WOF HEAL= AteIRIMANSERVXM 7 �AN�{L1PPOg
<br />VITAL CERTIF[CATF- nV FATU '' t l'F i� 1 A R n 1
<br />t. DECEDENT -NAM FIRST MIDDLE LAST
<br />2 SEk 3. DATE .7F DEATH :AbrYA DAY
<br />Raymond Richard Badsteen
<br />Male {December 13, 2000
<br />A. CRY AND STATE OF BIRTH /YAd p USA. RaTIICwftj
<br />Sa AGE - Lm OMfty
<br />I UNDER 1 YEAR
<br />UNDER / DAY 6. DATE OF BIRTH Monf Day Ysffl
<br />5b MOS F DAYS
<br />Franklin County, Nebraska
<br />" "175
<br />5,-"OURS ANN9 gust 19,'1925
<br />7. SOCIAL SECURTIY %UMBER
<br />ea PLACE OF DEATH
<br />507 -24 -5157
<br />HDSVrtu ❑ M1p88wI OTHER ❑ N..T H1.
<br />❑ ERoIp4wM Res
<br />Be FACILRY -Nw1I. IalY7YM1AIw19Y»aMwwNnu+Mw/
<br />Home: 3107 Magnolia Court
<br />❑ DOA ❑ DOW Slwd-.
<br />st. Cm. TOWN OR LOCATION OF DEATH ea INSIDE CRY UM1TS se COUNTY OF DEATH -
<br />Grand Island I Y. ®No ❑ Hall
<br />98 RESIDENCE -STATE , 2b COUNTY
<br />9c CRY. TOWN OR LOCATION
<br />Bo STREET AND NUMW R 10w9j*VZw Caael i 9e INSIDE CRY LIMITS
<br />Nebraska Hall
<br />Grand Island
<br />3107 Magnolia Court 68803Y.a ®,� ❑
<br />10. RACE - N.p. WHO.Owk.A wcm Mdw I It. ANCESTRYie q,..I*W, Aftmwt Camwt eel +2 MARRIED ❑WIDOWED
<br />/3 N�AtM�E�OFSPOUSE rp w#s pwmM7en nArnF/
<br />afe.l lCre161ye ISwcNyl American NEVER DIVORCED
<br />Caroline Adam
<br />14 °USUALYYiill11CC
<br />0RWATION /Gw6WaFrw*dxwdogm= top KIND OF SUSINESSNDUSTRY 115 EDUCATION ISpady 0,4 My" gram C-~
<br />Elep�aS�onOwy10 -1211 Cakge!140.5-I
<br />ror= Construction Company 1G
<br />16. FAT14ER -NAAR FIRST MIDDLE LAST MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />William Bftdste F en E=ia Leahy
<br />18. WAS DECEASED EVER IN US ARMED FORCES? 190 INFORMANT - NAME
<br />9 -19 -52 Caroline Badsteei,
<br />19b. INFORMANT MAILMADDRESS ISTREETORR.FD NO. CITYORTOWN STATE -1
<br />3107 Magnolia Court, Grand Island, NE. 68803
<br />• SIGNATURE 8 UC9i6E ti0
<br />21a METHOD OF DtSP09T 2 +D DATE 21C CEMETERY OR CREMATORY NMIE
<br />B,� ❑ gemaYa• Dec. 15, 2000 Grand Island Cemetery
<br />11 =70 CEMETERY OR CREMATORY LOCH T ICAV C.,-, I OP TOWN STATE
<br />- •NAME
<br />fel- Butler - Geddes
<br />❑`'°'""°' ❑ Grand Island, NE.
<br />22b, FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO CITY OR TOWN. STATE 21% -
<br />1123 West Second. Grand Island. NE. 63801
<br />23. BMFDIATE CAUSE TENT ONLY ONE CAUSE PEP LINE FOP .a: �>,1 ICIr Nlcrval Den18w: ansel arvt eea ►.
<br />PART
<br />% w (/yam �f1�� C
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<br />v l��ri
<br />DUE TO, OR AS A CONSEOUENCE OF - r<a+va1 aewwlan 0rw! ay.o Iva!'
<br />s�
<br />IW
<br />DUE TO. OR AS A CONSEQUENCE N - :�Ie -�'a: be!t.!1r� onsat roc oeav
<br />(W
<br />OTHER SIGNIFICANT CONDITIONS - C0110 c C lrft Oep n ow dulh blp,0 mylec 1 PARE w IF FEMALE WAS THERE A 2a AU -0ps, 25 WW-.5 ---SE RE
<br />PART .SE FERRED TO WW.AL
<br />PREGNANCY IN THE PAST 3 14ONTH$ 7
<br />a
<br />(— EKAMINEp OR CORONER'
<br />=Apes :0.501 Yes N0 � I Yes Nc I'a Yes
<br />280 DATE OF 9LIURY /Ik Day ri) ,26c HOUR OF INJURY ,260 DESCRIBE HOW INJURY iY'CVRRED
<br />i
<br />❑ ACCOM ❑ Urlowwm,nea
<br />_ M
<br />❑ Sl do ❑ Pak" 25e INJURY AT WORK ;261 a OF CRY %!V Ir.m steel, IaCby [269 LOCATION STREETORRFO NO 'DTY CR TOWN
<br />SAeC STAGE
<br />❑ Y+aA11GOa I Y. ❑ NO ❑
<br />I
<br />278. DATE OF DEATH NO Dar Y%! _- –'-
<br />I j 280 DATE SIGNlD ,AA, (�•. �. , ! itiC 11MR. LYF DEATH
<br />+QQ ^^
<br />27b. DATE SIGNED rMa DIY 1, - 2% THE OF DEATH - -� 8 12& UNCED DEAj As+ Pay. r,Y 2M Pp�YNU1p+C:E; -, D'cAp ,r — M
<br />M i Ss
<br />270 To IlebNld my Oad1 wrxa Nr+K! ewe A,c 01we am mm n C1e _ 28e O, the trills d e.a..m Ira 7. ++ws►gww.. :1,rrr vs a�.r,wT e
<br />Cw1l8I3) a18Y0. - t11e :ne awe wa ty c. n„+! M1,e w pw ca:Ae e, $106C �
<br />I e mW I 'S`Q i'L;e AM Tb2: 0
<br />29. 010 TOBACCO USE CONTRIM7VTOFTHE DEATYH 1306 HAS OPGNti OR TISSUE DONATION BEEN CO`G10ERED ,3:10 Y.'AS+:ONSENi G ^
<br />RANTS,•
<br />❑ YES E] NO ❑ YES!.! ❑ +E5 I� r
<br />31 PAW AND ADDRESS OF CERTIFIER MMY31C1Ah CORONEM S PHYSICIAN DR COUNTY ATTORNEY —'-
<br />�Sitki CopuS M.D. t 2115 W- Faidley Ave , grand Island NE. €8W3
<br />x. •+cw,.w. 32!'. DATE F?LEDljM11 Y �IL�
<br />L - — ��G ii4i�' lV8
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