|
WREN THIS COPY CARRNES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUM__AN SERVICES
<br />SYSTEK IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE90A (Wftt -3W1TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIE.'��[WI'gCNIS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />°AMA4�`�s0 22002 200206246
<br />ASSISTANT STATE iiCA/4' g -
<br />LINCOLN, NEBRASKA HEALTH AND)RI1 iAlfi ERyi`.E'S:>3kliiiT'EIIC°
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMANS F�A}�`=�y�lp'SUPPORT
<br />VITAL STATISTICS -
<br />CERTIFICATE OF DEATH 02 05287
<br />ENT NAME FIRST 'fIpOLE LAST 2 SE% 3 r. DATE OF DEATH IM Dav 1-1,
<br />Ra mo d J h
<br />y n
<br />o
<br />n Harder
<br />Male
<br />UNDER t DAY
<br />April 22, 2002
<br />6 DATE OF BIRTH IMOnN Da. vo-
<br />4 CITY ADD STATE OF BIRTH /n z{m USA. name counrryr
<br />Se qOc Lasl &nlrtlay IINDFR t YEAH
<br />Abbott, Nebraska
<br />DUF TO. OHASA rON5E0UENCEOF ”- - --
<br />' Inle,aal celween onset ano 9 ^a1n
<br />"'s' gl , MOS I DAYS
<br />5c HOURS MINB
<br />cI
<br />OTHER SIGNIFICANT CONDITIONS- Cwdilrocs mmnputin DI III IT FFEMALE WAS THEREA 2a ALTOPSV
<br />PART 9 ro l0e oeaP Om nOl relater P
<br />25. WqS CAaE RFFfflRED iC MEDICAL
<br />1
<br />E %0.MY. OR CORONER'
<br />February
<br />February 17, 1921
<br />SOGAL SECURTYNUMBER
<br />_
<br />An
<br />— -
<br />508 -01 -0048
<br />FG;P TAIL ❑ u'-I- OTHER
<br />❑ ER Outoarient
<br />❑ Na;mq Hem,.
<br />Resident,,
<br />90 FACILITY.Nama /root rnsrrNrrm. qve sr eei eitlnumber
<br />Home: 1308 West John
<br />L Smcrtle I] Pentllnq
<br />❑ DDA
<br />❑
<br />26g LOCATION STREET OR gFDNO :IlY OR TOWN STATE
<br />norn... mvesvgaven
<br />Yes G rvo ❑
<br />o e.s „tl W,_
<br />P T' TOWN pR LOCAIION OF DEATH
<br />-
<br />&I WIDE CITY LIMITS P¢ f.DUNTY OF DEATH
<br />2 4 a(m.r
<br />Grand Island
<br />AOalmnan,,
<br />�. Inallrne, 0e1e and OlaCE 1,T,, 101M1¢cau5015151dIM.
<br />Y ❑X NIn ❑ Hall
<br />29. III TOBACCO USE ^.ONTRIBUTE TO THE DEATH ? pd HqS DRGANOPTIS$IIF OONATIQV BEEN CONSIDERED'+ 9CO Wg5LON5ENTGRANTED'+
<br />9 E$IDENCF -SigiE 9,, COUNTY
<br />9c CITYTO NORLOCATION gd SIREFL AND NUMBER A.uCry Zrp COeer n NSIDF CrTY OMITS
<br />Nebraska Hall
<br />—RACE
<br />Grand Island 1308 West John, 68801 Yea ®No ❑
<br />IO. 'eg. Write. Black. Amencan lnd,an, II. ANCESTRY leq.Italian.
<br />Mexman Ge,man,eE[ I2 MARRIED ❑WIpOWED
<br />13NAMEOFSPOUSE 11-1e. 111,Ben name1
<br />nc15 q-01 White 'SAY,LR
<br />REV
<br />American l�COUNCED
<br />❑ MARRIED t
<br />Mary Jane Murphy
<br />Ipa LSUAL OCCUPATION /Grua klMGl work ACne purmg mruv
<br />AT --wAW. rr,evrAd)
<br />Inp KIND OF BUSINESS INDUS I RY IS FDVCATIgV SWI,f ly niglresl g�eee wmgtted
<br />-Clerk
<br />Flem¢nlary
<br />Union Pacific Railroad
<br />or��cm0,v'll 129 cmI
<br />L `�ei'T -'
<br />16 FATHER -NAME FIRST MIDDLE
<br />LAST
<br />O MOTHER BRET
<br />MIDDLE MAIDEN SURNAME
<br />John
<br />Harder
<br />Alvina
<br />Lachenmocher
<br />18. WAS DECEASED
<br />EVER IN U.S. ARMED FOFCESI
<br />19a. INFORMANT NAME -
<br />- - -
<br />(Yes. no. o, wk.
<br />191 yes give war aM dales of senicesl
<br />Yes:
<br />II 1 -5 -1943 12 -18
<br />-1945
<br />Mar y Jane Harder
<br />1308 West John, Grand Island. NE. 688111
<br />20. EMBAL14Efl -$IG �tTUHE6 LICENSE NO 21a METHOD OF DISPOSITION 21 p. DATE 21c CEMETERY OR CREMATORY NAME
<br />❑Bnnal ❑Removal Aril 25 200 Westlawn Memorial Park
<br />2A FUNERALHOME -NAME 210. CEMETERY OR CREMATORY LOCATION CITY ORTOWN STATE
<br />Apfel- Butler- Geddes ❑QNnAAn ❑Wna11w Grand Island, NE.
<br />220 FUNERAL HOME ADORES$ IST IEET OR RF.O. NO. CITY OR TOWN STATE.ZIPI -- --
<br />1123 West Second, Grand Island, NE. 68801
<br />20. IMMEDIATE CAUSE (ENTER ONLY ONECAUFF PER L INE FOR 9a - _ -
<br />'o!.nrvDlc. Irnervs eem'
<br />PART --A KY, aru r,urr
<br />1al Natural causes unknown
<br />- --
<br />DUF TO. OHASA rON5E0UENCEOF ”- - --
<br />' Inle,aal celween onset ano 9 ^a1n
<br />Ibl
<br />-
<br />DUF TO OR AS A01NEFOUFNCE OF Imerval berw¢en onset ano anon
<br />cI
<br />OTHER SIGNIFICANT CONDITIONS- Cwdilrocs mmnputin DI III IT FFEMALE WAS THEREA 2a ALTOPSV
<br />PART 9 ro l0e oeaP Om nOl relater P
<br />25. WqS CAaE RFFfflRED iC MEDICAL
<br />11 PREGNANCY IN THE FIST JNONTHS
<br />E %0.MY. OR CORONER'
<br />IA,e,ICSCI Yes NG Yes No
<br />Y. No ❑
<br />26,
<br />%tl DATE OF INJURY LW. Da�c HOUR OF INJURY
<br />2W. DESCRIBE HOW RUDDY OCCURRED
<br />Analdanl a 1IYc, rmined
<br />M
<br />L Smcrtle I] Pentllnq
<br />2Ee. INJURY Ai WORK
<br />26i PLACEOFINJURY- glnome lam. stem. Ra11,
<br />oMCa Wlldmp etc 15cea1y1
<br />26g LOCATION STREET OR gFDNO :IlY OR TOWN STATE
<br />norn... mvesvgaven
<br />Yes G rvo ❑
<br />A TE OF DE0.TM IMO Oay Yq 28a{�DATESIGNEO IMo Dayl ,A, THE OgIeL
<br />T11A
<br />M
<br />Apr11NCFC22, M20y02 >80 PR
<br />April
<br />(k^nwlDMq¢n¢aM
<br />2 4 a(m.r
<br />UCrs, Pd dl ln' el01oa 0EJldCedndtluP to ne���IV .. n M
<br />21:1 g
<br />SStYOIDmY
<br />wmvesrgW,I my opmon tlealn oaumen al
<br />2Ce O F. Oasis AT tnl
<br />caueP 515ble0
<br />AOalmnan,,
<br />�. Inallrne, 0e1e and OlaCE 1,T,, 101M1¢cau5015151dIM.
<br />�sr nelWaand rrael� 1St nawre and Tined 59i' �� :W
<br />29. III TOBACCO USE ^.ONTRIBUTE TO THE DEATH ? pd HqS DRGANOPTIS$IIF OONATIQV BEEN CONSIDERED'+ 9CO Wg5LON5ENTGRANTED'+
<br />❑YES ❑ NO ® UNKNOWN ❑ vES ® NO ❑
<br />YES NO
<br />31 NAMEANDADDRESSDFCEHTIFIER 'PHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY( rTV0.°a Rrnll -
<br />Sgt D Vitera, GIPD, 131 S ocust and Island NE 63801
<br />]2a REGSTRnq
<br />320. DATE FILED BY REGISTRAR (AO On,. 1(
<br />Pr1,
<br />MAY 8 2002
<br />EXHIBIT "A"
<br />s
<br />
|