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WHEN THIS COPYCAIbWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN._ SERVICES SYSTEM, IT CERTIFIES THE BELOW TO SEA TRUE COPYOF THE ORIGINAL RECORLI ON N+l'Tf� THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS S_1,4 =_ THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE JAN 2 8 2002 A /SIANLESR ASSISTANT SFATE REGlSTRAIi� >= LINCOLN, NEBRASKA 200207964 HEALTH AND HUMAN SERVICES SYSTEM STATE OF NEDRASKA• DFPARTMEWOF HEALTH AND HUMAN SMVKM FINAI ANb SU"Mt VITAL STAnSTICS n n n 5 5 9 rFuT mrATV Ar nRATTr i. DECFOUNT NAME FIRST NOME LAST 2 SEX G 3 DATE OF DEATH /M DIE,. q.d Beverl Jane Gronewold Female Jan 23 2002 <. CRYANDSTATEOF BIRTH /YngT USAIwN nMrpy) Se. AGE -IaV 9NgPY UNDERIYEAR UNUERI DAY &WTE 11F BIRTH /MnM. My YMO MDR. DAYS Sa. HOURS: -MM FY-) 56 Osmond, Nebraska 52 Jun 6 1949 7. SCML SECURITY NUMBER - KPIAOE OF DEPTH — 507 -68 -4226 HrosDRA<: ❑ bPaYa oTrHER: ❑ MWeag lbnre ❑ ER OI RNb fb. FACILRY -Rune ryG1or:1eN16RA yl¢y¢yulp,anEp -/ 3104 Midway Rd. ❑ WA El Dmal IS.0' ft CRY. TCWNCQLCCI.cFDEATH M INSIDECITYUMITS Be. COUNTY' OF DEATH Grand Island Yas ❑X Nn ❑ Hall 9¢ RESIDENCE -STATE W. COUNTY 4. CITY, TOWN OR LOCATION PS STNEETANDNUMBER IWc V2,,C ) 9e. IN$IDE CRY LIwTS Nebraska I Hall Grand Island 3104 Midway Rd. 688031 Y« X No ❑ 11 RACE -(¢a.. WNM BA*'ArWrR. M. tT ARMSTRY R,'.Ilalin. W..n, 0anren.ab) 12 ® MARRIED ❑WIDOWED 13. NMAEOFSFOUSE fa 6 yAe maOSn narrgl Ncl F5 Ny) White Is Iyl German Swedish xEVER DIYp9OED M Donald Gronewold IAe UWALOCL "N"ON 'U"E"M070pg9ngmop lib d•otaipaM eYMYMpBtl/ KMDOFSUSINESSINDUSTRY _ 15, EDUCATION ISpeoI,p hgiaalgeOe cmlpleNtfl EMIreIGyZ SemnMery (0-121 CdKge 11 o, s•I - -- 1 Y! Licensed Practical Nur IO. igTHER. NAME FIRST MIDDLE EAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Allen Johnson Elva Mae Jensen 1 iB. WAS DECEASED EVER IN U5. AIMED FOf10E59 19a INFORMAM-NNAf (Ve¢ro.nw) MWa.gre.a and aueedearACeai Donald Ray Gronewold _ 1% INFORMANT MAIEJIIG ADORESG ISTREET OR RE. D. NO.. CITY CA TOWN. STATE. ME) 3104 Midway Rd. Grand Island NE 68803 $ . EMBALMER - SIGNATURE 6 LOFNBE RO, 21¢ METHOD OF DGPOSTDON 210, DATE 21c. CEMETERYORCREMATORY -NAME Not Embalmed ❑BEM ❑,�j1p ' Jan 23, 2002 Central Nebr. Cremation 22a FUNERALHCNE -NAME 2IE. CEMETERYORCREMATORYLCC MIN CITY OR TOWN STATE r P] ❑D 8"" Curran Funeral %a al 719 Front St. Gibbon NE 220. FUNEMLHOMEADDRESS I$TREET OR RF.IT RLI CRY OR TOWN STATE➢P1 3005 South Locust Street Grand Island NE 68801 23. MMEMATECA IENTER ONLY ONE CAUSE PER EWE FOR (a). b } AND k)) trie,Vd ONlvOen aNel vd ouln - PMT J' /UJ Q WE TO. OR AS A MNSEOWiCE OF. Mbval I1eMean o1m1 w ceam 099E TD, OR ASACONSEOIATJCE OF - � I mMrvalpNMln olleAleM Oaam I � t OTHER 54MF'TCANT CONDITIONS- Cg6tlona oaMMdnpb OS Seim bul Mral�.t M+Nif1IFFEMALE PART WAS IREREA UTOFb^2 a1 F PREGNANCY N THE PAST 3 MONTHSi ElfAMRJER ORCOTONEMMF.00AI. (A i s 10.5CI - Y. Np Y® 1b Y. - 26a. 906 lMTE OFIIAA9RY dfx Dry. r.J 2PC. HOUR OF tlUURY M DESCRIBE HOW INJURY OCCURRED _ AcciEeN U"URannNeE El El N ❑ Sui'iM ❑ PM' NIP.*LURYATW 2& 9h9=0UIGRY f[U Tglp.larm. eYpet bl}y FYI Mg LOCADCN STREET OR RFD .N0. CRY OR TOWN STATE ❑ H1onxMe N^GaNYSM Yu ❑ W ❑ _ Zit DATE OF DEATH /Ma' N, 2H. DATE SIGNED fW, Ray Y, MT TIME OF DEATH ^Y�J S M �} DATE SONE'JO db..Dry. Yrl 9CTME OF DEATH'y 20c. PppiWNCED OFAU 94a. iMy h/ 2BB. PRONOUNCED DEAD IHwv) 8 —�Y�� �2 A•M' � M'- 8° TO b90eRdnitnaANEG a Cabll rcavre0 a[tla MN aM Wse and hn blle 28e. OnIlp COeYdemnnmm vMlrt xan occunma uwefsl Brae { { °u a me Gar. me rd dace arM drnwPawe(�,el ale a.�on MMT K ISW. and TYa ► CONTRIBUTE O $pO TOBACCO UGE 09GIXTW ED2 YES 11 NO UNNNOWN �3b,WASCCNNG. 1:1 YES 31. NAMEANOAOOPESSOFCERTi t'l YS KAAMCORONEHSPHYSILNNORCOUNTYATTORNEY) fTypea RirYf Sitki Co ur 2116 W. Faidley Ave. Grand Island NE 68803 32¢ REGISTRAR 320. MTE FLED BY REG151RAA dR" Yr/ JAN 2 5 2002 _ ? G _- -U, r