. w
<br />P 1 ' AEI T
<br />r . �:• I 'cap .c •,
<br />• a 3 v �i
<br />•
<br />- I
<br />.,
<br />III FACILITY
<br />OIIIiI '
<br />x ...
<br />CRY
<br />PC •, ..
<br />N.
<br />'.
<br />9L FIF i
<br />3'Ih
<br />Kul
<br />Gdklslam ��_ ,;�
<br />4 68801
<br />fffQ
<br />�IIMII! •, q Ift"-
<br />Iwe.11Sp,1cJly1
<br />F.ANCESTFF((9.9,.1WiIWM8K1pw "Go 12 n MARRIED ❑ YNDOMIFD
<br />ISnee 1 l�.F
<br />13. NAME OF SPOUSE /M wAe. gi.Y m6den name)
<br />} ` -
<br />EV�T DnroRtEn
<br />Ileanre 1Sjkers
<br />Wh to
<br />r sh German
<br />Ide. usuA�occlwATloN. lcra•iilda da•.er.:+aw
<br />, t :`
<br />is
<br />ar Ilwe.sal
<br />'
<br />Owtier
<br />o tra t4:.,
<br />IS. FATHER, NRME PAST; MIDDLE - t*T ..
<br />17. ., a _ ry
<br />in CC
<br />Axi $actei?s .
<br />it WAS . Q-:f -
<br />(YOL no. %K U*4 la Yes: 9",W and dart M Ngiftel
<br />.NAME
<br />.. . -. ....•.. # . a ", .. ,.:, d e
<br />9
<br />r �
<br />e G.
<br />19b, WFORMAW MAILING AODREES " (STREET OR f O NO-OFFYOR100W. STATE. aPf
<br />2915 W. Hwy 34 , Gr nd gland, Ithraska 68801
<br />2F-EMBALMER - SIG ATUW ..
<br />21i MFIDIDD 011 QI
<br />ib- DATE 3P14, CEMtTERTQNC, ATQgY NAME.
<br />August 13, ,l9 H :'We�tlmn f.mqmorial Park
<br />214 OR CREMpp(�T -LDCA ; s - CI v Oq i STA E 4 ,
<br />.
<br />22a. fUNFAl1l FIOME -NAME
<br />Kleine Funeral Home ' z �, i 1- °
<br />[�c,..,r,^` Dona •n
<br />171 i. -fv
<br />1
<br />u a• ; I bkg ka _-
<br />� .
<br />-:
<br />22b. FUNERAL HOME. ADDRESS 1ST Ri.D. NO.. CITY TOWN. STA
<br />3213 W. North Front Street GrAAd 'Islenc Nej)raska 6 803 1
<br />23. IMMEDIATE CAUSE - --[VMR . CRUSE UNE FOR W la, a ten d s -.$ p 1 ., }... .. ••. T jai' •M�sn a" and WMn .�..-
<br />PART /- _
<br />lal lag&
<br />DUE TO. A �. .. -o t ...MMOI ►81 C!lRlM aM01 >!!!d. .
<br />.. '
<br />x'
<br />DUE 70.OR , . ' ,.. I _...
<br />j .;
<br />OTHER SIGNIFICAWOONDITOONS • Car WSgrls beie Maal dA.rg1 nwwad PART PREGNANCY MV IIf 1F F WAS A d AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />PART PAST3 MONTHS? EXAM94ER OR .�.
<br />C
<br />9
<br />((Agee _y ',y LAO, Y No Yes Nd
<br />: 4.. ]
<br />26a. `2b. - D�A%TE !M0. AW. V j 26c. HOUR ill! WARY mod. DESC ' -, 1Ei 9i
<br />` ' " '� -. ... . ^R } •""""e
<br />�:
<br />� /J/�'
<br />..
<br />fif Aeeidws ❑ Lkw",.med 4 .:. 2 : 1 - i . M a M /1✓"' -�.r.. r
<br />❑ Suicide ❑ Pa." 26a. INJURY A
<br />LlttgAy rert 3"a f6i" - 26g Lf1"WW 5 OR iiF O. IQO CITY Qq TOM - . STATEY
<br />jM.-W&%ZMW
<br />-❑ -2 a
<br />27a. DATE OF 050TH F.. y. Yij... ..
<br />2071. SATE /Mb.. glyt Trl - 26e TIME 11EATN '; �.
<br />a la _
<br />S
<br />•
<br />.. M
<br />SS
<br />88°
<br />26e DEAD /Md. a4: Yr.) 26s PA( WOUNCEO DEAD... «p
<br />27b. DATE . Yrl
<br />27a TIE OF DEATH
<br />.°
<br />7s
<br />260 On 6tb 6Mi, afs>NIII�"jalbll +yXl[Qi .: F oIY Opneon 0• ! aeGllrbtl at -'.p
<br />�
<br />27d: To .' owl and OK anll Ou• q the
<br />eau>r(sl
<br />$
<br />el• amt dar aM M77u alldaus r�wsbd. , •
<br />.r:
<br />29. DID TOBACCO USE
<br />.,
<br />'.... ,. BEEN
<br />D?
<br />..
<br />36 Y MIAB:CONSENTGRMN - -- a -...
<br />.,.
<br />Q VE3 N0
<br />YES ®
<br />ILO
<br />.•. AftE t
<br />YES ; ,^ _{{, ......>
<br />31. NAMIE AND OF C114TIF04, fPNYSICJAK NIX ATT 1 (Tlplo Prig
<br />L L
<br />32a. REGI 7RAR , e, 4 .... 32b. DOTE v REGISTRAR ptn, . w.! - ....,.
<br />-� AUG 1997
<br />.15
<br />+
<br />
|