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*WIN TI MS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMMAINHWa"
<br />SYSTEM RCERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE ,.bNFR.�W[TH
<br />THE NEBRASKA HEALTH AND HUMAN SERWCES SYSTEM, VITAL Ism Tis I6'S.lf6pio F€IS
<br />n, ivies
<br />THE LEGAL DEPOSITORY FOR WTAL RECORDS. A. ! _.
<br />DATE OF 2002 CE A7 H PYS V DER
<br />JUN 2 6 2002 2 0 0 2 0 719 oZ ASS /STAiYT STATE,REGI$TRxR
<br />LINCOLN, NEBRASKA - HEALTH AND ,H0MANSERWCES 'STEIIE-
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERWE$FWANCEA14D AWOK IT
<br />VITAL STATISTICS (} 0-7266
<br />CERTIFICATE OF DEATH —= 0 2
<br />NAME F1w51 Lli
<br />DF('�REn'- 'Ji JLL IASI 25E% f I neTf nc nc— -
<br />PFEGN
<br />°I1
<br />m
<br />S D
<br />Henry Werner
<br />Male
<br />June 16, 2002
<br />� 4 CITY AND STATE OF FIRTH .n noun Ll.SA name.......
<br />Sa ED Lael Igmal UNJEH I YEAR
<br />Y
<br />UNDER ( DAY . GpATE OF F.I.T. BIRTX IMgMh 0.a ✓ve.vl
<br />Grand Island, Nebraska
<br />71 Nm DAYS
<br />Z
<br />I,JU
<br />December 21 1930
<br />P socaL SECURTIY n MIL
<br />N
<br />_
<br />sa +LAC'E CF DEATH
<br />Ni
<br />506 -28 -8574
<br />r
<br />OTH =_a ❑ Nareny Ham,
<br />-
<br />M FACILITY_Name -- ,,,ml.nsluulkn. g; ✓a sl.ea, arrtl numpevl
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<br />D G
<br />1705 Ando Street
<br />❑ DOA
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<br />o
<br />CD
<br />01 CITV TOWN OR LOCATION OF UEPTH
<br />1L O
<br />r0
<br />X
<br />= N
<br />1
<br />Yaa p ❑
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<br />C T-
<br />m
<br />fV
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<br />91 01 Y. TOWN OR LOCAT109
<br />v ,
<br />Nebraska 1
<br />Hall
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<br />mph
<br />1705 Ando Street Yee ❑x NP [
<br />IO RACE, ley.Mi I ect Amencan lMian.
<br />1 ISWT&'
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<br />0
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<br />V
<br />1]NAME OF SPOUSE 1I' -7 give ma —namel
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<br />°
<br />DwORDER
<br />cn
<br />CD -n
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<br />Iv
<br />y
<br />Painter
<br />Paint Contracting
<br />ElCmenla'° o, sewmaw IG Izl coI19P9 , 4 o .
<br />12 1
<br />16 FATHER NAME FIRST MINGLE
<br />LAST I! MOTHER
<br />n
<br />CZ)
<br />H
<br />Helen Schmitz
<br />IB WAS DECEA IFU
<br />_
<br />FbER IN US. ARMFC FILETS F
<br />19a. INFORMANT -NAML
<br />rn
<br />ro.a "'
<br />Jl Des.""P- " "d tlales.1 imYmsl
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<br />Na
<br />�19p
<br />Connie Werner
<br />CID
<br />OR R FD NO CITY OR TOI':N SI AT' , IPI
<br />1
<br />Cn
<br />f✓
<br />CM
<br />CID
<br />M E MER -SG R LICEN 0
<br />�21a METHOD OF DISPCSITION
<br />2lb DATE
<br />'211 CEMFTFRYCHCHLAn.11JRY NAME
<br />(H7 t#1071
<br />❑X Banal ❑ Reme ✓m
<br />June 19,
<br />2002 Grand Island City Cemetery
<br />2 UNERALHOME NAME
<br />1210. CEMETERY
<br />ORCREMATORY LOCATION CITY OR TOWN STATE
<br />All Faiths Funeral Home
<br />Lzb
<br />❑ clameron ❑ da"T"
<br />C. 0
<br />Cfl
<br />N
<br />Z
<br />Q
<br />As
<br />C2
<br />K
<br />Lot 3, Block 4,
<br />Kay Dee
<br />Sub. in pt.
<br />of the SW4SW4
<br />21 -11
<br />-9 in
<br />Village of
<br />Parkview, Hall
<br />County,
<br />Nebraska.
<br />*WIN TI MS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMMAINHWa"
<br />SYSTEM RCERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE ,.bNFR.�W[TH
<br />THE NEBRASKA HEALTH AND HUMAN SERWCES SYSTEM, VITAL Ism Tis I6'S.lf6pio F€IS
<br />n, ivies
<br />THE LEGAL DEPOSITORY FOR WTAL RECORDS. A. ! _.
<br />DATE OF 2002 CE A7 H PYS V DER
<br />JUN 2 6 2002 2 0 0 2 0 719 oZ ASS /STAiYT STATE,REGI$TRxR
<br />LINCOLN, NEBRASKA - HEALTH AND ,H0MANSERWCES 'STEIIE-
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERWE$FWANCEA14D AWOK IT
<br />VITAL STATISTICS (} 0-7266
<br />CERTIFICATE OF DEATH —= 0 2
<br />NAME F1w51 Lli
<br />DF('�REn'- 'Ji JLL IASI 25E% f I neTf nc nc— -
<br />2929 South Locust Street, Grand Island, Nebraska 68801
<br />23. IMMEDIATE CAUSE IOM ER ONLY ONF CPI F 3R LINO FOH D. AND Iqi
<br />PART
<br />a Natural causes
<br />DUE 10. OR—AS N COISEOIENC 01F
<br />IN
<br />F"-, 'S A CoN SFOUFNCFI
<br />unknown
<br />I m'-a' celweeq oneCl aM HP,
<br />OTHER SIGNIFICANT CONCRIONS- Cmo'io15c 91Olne death EN N YO len
<br />PART
<br />PFEGN
<br />°I1
<br />2S
<br />Albert
<br />Henry Werner
<br />Male
<br />June 16, 2002
<br />� 4 CITY AND STATE OF FIRTH .n noun Ll.SA name.......
<br />Sa ED Lael Igmal UNJEH I YEAR
<br />Y
<br />UNDER ( DAY . GpATE OF F.I.T. BIRTX IMgMh 0.a ✓ve.vl
<br />Grand Island, Nebraska
<br />71 Nm DAYS
<br />, XoGRS MINs
<br />I,JU
<br />December 21 1930
<br />P socaL SECURTIY n MIL
<br />N
<br />_
<br />sa +LAC'E CF DEATH
<br />, -- -
<br />506 -28 -8574
<br />HosPITAL ❑ ✓I.I.P,
<br />OTH =_a ❑ Nareny Ham,
<br />-
<br />M FACILITY_Name -- ,,,ml.nsluulkn. g; ✓a sl.ea, arrtl numpevl
<br />- ❑ ER
<br />Dmpa4em O Nesitle'e,
<br />1705 Ando Street
<br />❑ DOA
<br />❑
<br />ED d' Ony P'I 280 TM OF DEATH
<br />olne„see.a _ ___
<br />01 CITV TOWN OR LOCATION OF UEPTH
<br />Ad INSIDE CITY LIMITS
<br />2e COUNTY OF DEATH -- -" --
<br />Grand Island
<br />2fltl PRCNJ N EC pE0.0 (I. c
<br />Yaa p ❑
<br />Hall
<br />9a RESIDENCE -STA1l
<br />Gb COUNTY
<br />rol N' y
<br />�0 4 wl Ng leell "Aal met' flea -q elll eel tlaemne
<br />ea
<br />91 01 Y. TOWN OR LOCAT109
<br />9tl STRFETANDNUMRER ✓ndutlmg Dp CeCC; 13e INSIOE CI TV LIMi
<br />Nebraska 1
<br />Hall
<br />M a ,e hee o 1 - al slat c.
<br />Grand Island
<br />1705 Ando Street Yee ❑x NP [
<br />IO RACE, ley.Mi I ect Amencan lMian.
<br />1 ISWT&'
<br />11 ANCESTRY leg
<br />Malian. Mex¢an Gelman ahl
<br />12.y MARRED
<br />�J
<br />L) WIDOWED
<br />1]NAME OF SPOUSE 1I' -7 give ma —namel
<br />ele
<br />White
<br />1Scemry1
<br />American
<br />NEVER
<br />❑ M0.R
<br />DwORDER
<br />Connie Dubas
<br />14a USUAL OCCUPATION lGire km�d wor41klr1e Mn,y must
<br />b womng Ilk, even ilreveal
<br />140 NINA OF BU51NE551NOUSTRY
<br />15 EDUCATION �SVecMy ��ry nippesl (Jrane mn�Plalatll
<br />Painter
<br />Paint Contracting
<br />ElCmenla'° o, sewmaw IG Izl coI19P9 , 4 o .
<br />12 1
<br />16 FATHER NAME FIRST MINGLE
<br />LAST I! MOTHER
<br />FIRST MIDULE MAIDEN SURNAME
<br />Albert
<br />Werner
<br />Helen Schmitz
<br />IB WAS DECEA IFU
<br />_
<br />FbER IN US. ARMFC FILETS F
<br />19a. INFORMANT -NAML
<br />—' -
<br />ro.a "'
<br />Jl Des.""P- " "d tlales.1 imYmsl
<br />Na
<br />�19p
<br />Connie Werner
<br />INFORMANT MAILING AGREES S 'STREET
<br />OR R FD NO CITY OR TOI':N SI AT' , IPI
<br />- - - -- -- - --
<br />1705 Ando
<br />Strcet, Grand Island, Nebraska
<br />68803
<br />M E MER -SG R LICEN 0
<br />�21a METHOD OF DISPCSITION
<br />2lb DATE
<br />'211 CEMFTFRYCHCHLAn.11JRY NAME
<br />(H7 t#1071
<br />❑X Banal ❑ Reme ✓m
<br />June 19,
<br />2002 Grand Island City Cemetery
<br />2 UNERALHOME NAME
<br />1210. CEMETERY
<br />ORCREMATORY LOCATION CITY OR TOWN STATE
<br />All Faiths Funeral Home
<br />Lzb
<br />❑ clameron ❑ da"T"
<br />Grand Island, Nebraska
<br />F UNL6ALROME ACOPe's _.._
<br />.+ STREET OR RFD NO. nry OR TOwN.
<br />STATE. zIPI
<br />2929 South Locust Street, Grand Island, Nebraska 68801
<br />23. IMMEDIATE CAUSE IOM ER ONLY ONF CPI F 3R LINO FOH D. AND Iqi
<br />PART
<br />a Natural causes
<br />DUE 10. OR—AS N COISEOIENC 01F
<br />IN
<br />F"-, 'S A CoN SFOUFNCFI
<br />unknown
<br />I m'-a' celweeq oneCl aM HP,
<br />OTHER SIGNIFICANT CONCRIONS- Cmo'io15c 91Olne death EN N YO len
<br />PART
<br />PFEGN
<br />°I1
<br />2S
<br />PRE'NA NCV INTHE AS fiH9OHEDyaAUT�S
<br />E %A:IVNE90R 1]R
<br />Ile
<br />�LE MRL9FY4pW
<br />N�1111.;AI
<br />I,I
<br />26 ARE DAIEOFIWVR ,,,. Jay vrl
<br />26c HOAR OFINJL v
<br />I,JU
<br />I� A.. tlanl 'L Pm
<br />nwcMa we
<br />_ �—
<br />6e INJURV 4I-WON rl PH.AOEp OFII, AD <Speap a
<br />o
<br />nl lanary
<br />STREET ORR p. >' O nv pR iOWN STP❑
<br />Yac F 1 NC ❑
<br />m2/ae
<br />7�CaTTSJ((6"N
<br />U-- OF 11F -- ,1
<br />— K J vcl
<br />ED d' Ony P'I 280 TM OF DEATH
<br />2]0 —�
<br />DA SC v ME61 DEATH
<br />G -�i ce 9:00 am_
<br />28e PRONOUNCD F EAD AV Day. Y
<br />� .
<br />2fltl PRCNJ N EC pE0.0 (I. c
<br />(June 16 2002
<br />9 35 act
<br />rol N' y
<br />�0 4 wl Ng leell "Aal met' flea -q elll eel tlaemne
<br />ea
<br />�O -be m 9 n I ea n oc netl a
<br />a eb
<br />-
<br />M a ,e hee o 1 - al slat c.
<br />.Ones tl Ti" IF _ _
<br />IS nalum a� T e �L<
<br />29 OOTOUAOCO USF i.ONTRIGUTE TOT DE0.TH1 �. MHPS ORGAN UR TISSUEDONATIONGEENCONSIUERECI
<br />3O.p WgSCONSENT GgANTECI
<br />❑ YES ❑ NO IN UNKNOWN ❑
<br />YES 010
<br />❑ vES NO
<br />31 Ng ME AND ADDRESS OFCEH ANNE ( PHYSICIAN, CORONLR S PHYSICIAN OR COUNTY ATTORN -Y,
<br />-
<br />ce ar hurry
<br />Sgt D Vitera, GIPD, 131 S Locust,
<br />Prand Island, NE 68801
<br />]2a RcGISTRAR
<br />- - -
<br />92b CAIE FILED BY REGISTRO� 1/d. llay YrJ
<br />
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