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<br />` WHEN THIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, TT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD -Ol WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTIOM, WHICH IS.
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. �,�'��'�j � _
<br />DATE OF ISSUANCE 2 0 0 2 0 7 4 4 E r/ 6TA�`/'f/ NLEYS PER
<br />UUL 2 6 2001 ASSISTANT STATE REGISTRAR,
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE, OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE-AND SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF D_ EATH -
<br />I CEIPUIII. NAME FIRST MIDDLE 1AST .. sEx ?DATE Or DeaTH- ni;r.�.
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<br />Se ME Las10:oNeaY
<br />UNDER I YEAR
<br />UNDEHIDAY
<br />6. DATE OF RIRiN rAbnln Oal 121 11
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<br />' SSIALSECUHIIYNUMBER
<br />BE PLACE OF DEATH
<br />RARf`J E"-
<br />11insufficiency, thoracic, cerebrovascul
<br />HOSPITAL ❑ I....... OTHER ❑ Nu ... -, Hem,
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<br />B¢ COUNTY OF DEATH
<br />Grand Island
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<br />_'DENCE -STATE 9e CWNTV 9c CITY TOWN GH LOCATION 90 STREET ANO NVMBER /hrwerny dp CO°el 9a INSIDE CITY L,M115
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<br />16 FATHER -NAME FIRST MIDDLE LAST / MOTHER FIRS, MIDDLE MAIDEN SURNAME
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<br />B 11AS DECEASED EVER N U 5 AHMED FORCES"+ W W 11 IBa INFORMANT - NAME
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<br />! yes [Dec. 1944 /Nov. 1946 Heidi Watson
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<br />119°INFORMANT MAILINI IINt B.1 111.". In n 1 u n., . ur,— IB.—a —i, u.r
<br />4003 Mason Ave. Grand Island, Nebraska _ 68803
<br />1 10 � ALMER -SIGNA E ENS 21 d. METHOD �D15PO5R10M 11e DATC � 11c
<br />�� ©amm ❑Remn.a. Dune 28 200
<br />FORMAL DOME -NAME 1110 CEMETERY OR CREMATORY LCCAI
<br />Lockenour -Jones Mortuary ❑adm, "° ❑mna on Bartley Neb.
<br />7ID 1UNFMLMOMEADORE55 ISIREEf OHHFO NO CITVORTOWN.
<br />STATE. ZIPI
<br />P.O. Box 3_86 Cambridge Nebraska 69022_
<br />!:ITV AND STATE OF BIRTH nr nol ur USA ndme [CUMIN
<br />Se ME Las10:oNeaY
<br />UNDER I YEAR
<br />UNDEHIDAY
<br />6. DATE OF RIRiN rAbnln Oal 121 11
<br />5C NOS DAYS
<br />5c HOUR$ MINS
<br />', approx. 25 years
<br />IYrsl
<br />onsernn-lnn
<br />Brook Park, Minnesota
<br />74
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<br />September 6, 1926
<br />' SSIALSECUHIIYNUMBER
<br />BE PLACE OF DEATH
<br />RARf`J E"-
<br />11insufficiency, thoracic, cerebrovascul
<br />HOSPITAL ❑ I....... OTHER ❑ Nu ... -, Hem,
<br />482-24-2990
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<br />4003 Mason Ave.
<br />❑ EGA ❑ olna. sn.. n __.. - _
<br />& EIIV OBNORIOCTIIONOFOEITH
<br />Oe INSIDE CITY LINITA
<br />B¢ COUNTY OF DEATH
<br />Grand Island
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<br />_'DENCE -STATE 9e CWNTV 9c CITY TOWN GH LOCATION 90 STREET ANO NVMBER /hrwerny dp CO°el 9a INSIDE CITY L,M115
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<br />Nebraska Hall Grand .Island 68803_ -j_
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<br />Al Scciryl NCVEfl
<br />I Whit e._ German MA R, 0 - DIVORCED Catherine S. klarsch __.
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<br />16 FATHER -NAME FIRST MIDDLE LAST / MOTHER FIRS, MIDDLE MAIDEN SURNAME
<br />Gerhart Henry Hans Jur ensen Anna _. Bundtzen______
<br />B 11AS DECEASED EVER N U 5 AHMED FORCES"+ W W 11 IBa INFORMANT - NAME
<br />Il ealPS d
<br />Ink ye¢ g.¢ waraM servws)
<br />! yes [Dec. 1944 /Nov. 1946 Heidi Watson
<br />119°INFORMANT MAILINI IINt B.1 111.". In n 1 u n., . ur,— IB.—a —i, u.r
<br />4003 Mason Ave. Grand Island, Nebraska _ 68803
<br />1 10 � ALMER -SIGNA E ENS 21 d. METHOD �D15PO5R10M 11e DATC � 11c
<br />�� ©amm ❑Remn.a. Dune 28 200
<br />FORMAL DOME -NAME 1110 CEMETERY OR CREMATORY LCCAI
<br />Lockenour -Jones Mortuary ❑adm, "° ❑mna on Bartley Neb.
<br />7ID 1UNFMLMOMEADORE55 ISIREEf OHHFO NO CITVORTOWN.
<br />STATE. ZIPI
<br />P.O. Box 3_86 Cambridge Nebraska 69022_
<br />1] IMMEOIATECAUSE [ENTER ONLY ONECAUSE PER HIRE FOR aI 101 A`U TH
<br />Inver. -al OY. —Truer dn0°,:,..
<br />In I AT Multi- system failure _
<br />- approx. 2months_
<br />DUE TO OR AS A CONSEOUFNCE OF
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<br />advanced cerebrovascular disease and prior CVA
<br />', approx. 25 years
<br />_... , p1
<br />' DUE iO.ONA$ACDNS000FNCE OF
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<br />y RT III IFFEMALH WAST
<br />WAS A S
<br />'2a AUTOPSY
<br />PS WAS GAEL REFERRED TO Mf.DICA.
<br />EXAMINER OROOHON O
<br />RARf`J E"-
<br />11insufficiency, thoracic, cerebrovascul
<br />YRfGNANCYINLE THERE
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<br />I1 egen -rat ive26pj29y1atde1dli sp8'$ er.
<br />16c HOUR OF Al
<br />2,d DESCH1DENOWINIURIOCCURRED
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<br />_ L r36BDItVRV F K P QE FINIURV -Apo _11ac1rvy 12S, DUCAHON STREET OH H FU NO GPV OR TOWN STa[E
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<br />❑ nam1CM¢ o-re,,aRr y, ❑ No ❑ m
<br />Illy nA r DEATH m _-
<br />a DAIS MO SIGNED / , n 2Do TIME OF DEATH
<br />e OF oar v/1 28
<br />June
<br />2001 20c PRONOUNCED DEAD .I_Mo _ C. AP 1tle PROnO_U.. NCEDUEAD /11-11
<br />;1AJE u SIeGNED (M6 OWy N, TIME OF OFA
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<br />(o Tr,I p Ini myx Gee ur e11 place alM due to In, 4 io 2Ee P'rN pe adeiam nalon ane or oyes 9al°r, nnyopn curlrp a:
<br />Oa
<br />cau- -I alga s a k and WYC. ane cup o ne causes UNUM
<br />In JD TOBACCO USE CONTRIBUTE rH+ 30a HASORGAN DONArIOWEE IN CONSIDERED' i3En WAS CONSENT GRANTED' �
<br />❑ VE$ NO ❑ UNHNOWN ❑ YLS O No ❑ YES LJ NG
<br />,_Nebraska - .68.803
<br />/REGISTRAR IW On, ry
<br />JUL-0-2 2001
<br />
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