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<br />r SOCgL SECURTIY NUMBER 18a PLACE OF pEA1H
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<br />No I George Pontious Sr.
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<br />22a FUNERAI-11i NAME 21C CEMETERY OR CREMAURV COi .u10WN SIn1`
<br />fel- Butler- Geddes ❑ "em "' ❑D°"a40° Grand Island, Nebraska
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<br />November 26 2000
<br />SYSTEM, IT CERT FES THE BELOW TO SEA TRUE COPY OF THE ORIGINAL RECOR"N#XjrWftr
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<br />27c TIME OF DEATH
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<br />Fern Mildred Pontious
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<br />CRY AND STATE OF BIRTH rXnNq V S4. nam¢munny, Sa AGE Lael6mbbav 'UNDER I YEAR UNDER I DAY 6. DAIE 01 BIH "1 U., Oa, vpan
<br />DAYS 5C HOURS M1 July 26, 1916
<br />Belgrade, Nebraska %4 51 MDS I N3
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<br />505 -36 -8633 HOSPITAL ❑ „oalianl OTHER ® ho,""b',
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<br />Be CITY TOWN OR LOCATION OF DEATH ea INSIDE CITY LIMITS 0e COUNTY OF DEATH - - --
<br />Grand Island vaa 'F1 N:: ❑ Hall
<br />9e RESIDENCE STATE 9J COUNTY 9c Cli TOWNOPLOCATION 90 STREETANONUMBER /l ',,1lg 2; +.'nfe, 68803 T, INSIDE CITY TWITS
<br />Nebraska Hall Grand Island 4018 W. Old Potash Hwy N, ❑
<br />10 RACE -leg- Wnlle- Black Axncan moil” IL ANCESTRY mg Malian. MY1111". Oerman. NC' 12 MARRIED ❑WIDOWED 119 NAME OF SPOUSE Ew, /e. p,re Till.e" namel
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<br />White American ❑ MPPI George Pontious Sr.
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<br />16.FATHER -NAME FIR51 MIUULE LAST t] MOTHER FIRST MIppLE MAIDEN SURNAME
<br />Floyd B. Giersdorf Laura Fritzes
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<br />1% INFORMANT MALL INC, ADDRESS 'STREET OR R FD NO CITY OR TOWN S I A I E LIP(
<br />18 W. Old Potash Hwy, Grand Island, NE. 68803
<br />EMSAILVER - SIGNATURE B UCENSENO 93 21a MEMODOFO'SPOSR'OK 2ID.DATE 21, CEME1ERYORCPEVA,0. NAME
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<br />22a FUNERAI-11i NAME 21C CEMETERY OR CREMAURV COi .u10WN SIn1`
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<br />22, . FUNERAL H0ME ADDRESS (STREET OR RF.p NO CITY OR TOWN SATE. ZIP)
<br />1123 West Second, Grand Island, NE. 68801
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<br />2d 26b DATE OF INJURY ("I Day. Yr.l 26C HOUR OF INJURY 26b DESCRIBE HOW INJURY OCCURRED
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<br />9a. DATE OF DEATH (b Day Y,J
<br />20a DATE SIGNED /MO Day Yrl 28e TIME OF DEATH
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<br />2Ib DATE SIGNED (NO WE Y0
<br />27c TIME OF DEATH
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<br />❑ YES ❑ NO
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<br />31. NAME AND ADDRESS 04 CERTIFIER PHYSICIAN. CORONER C PHYSICIAN OR COUNTY ATTORNEY( r1R, N Pnep
<br />Ryan D. Crouch D.O. 890 N. Alpha Ave., Grand Island, NE. 68803
<br />W. REGISTRAR
<br />221. DATE FILED RY REGISTRAR !MO. paV Yq
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