200208717 - Laserfiche WebLink

Browse

V Il WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND MMKNSERVICES SYSTEM, IT CERTIFIES THE BEL0 W TO BE A TRUE COPY OF THE ORIGINALRPCOM ON F_ IEEYAM THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS: SECrm vmbH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE �OppF ISSUANCE qq 200208717 ANLETS R UUL 5 2002 ASSISTANT STATE REGISTRAR LINCOLN, NEBRASKA HEALTH AND7A)MAN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERIW ES FM CE_A5&si{7PPORT VITAL STATISTICS CERTIFICATE OF DEATH 02 07567 II DLCEDE17 - 1:A'!E FIRST MIDDLE IPST JC% A n Male June 21, 2002 i ODYANDSTATEOFOIRTH Ilmo,vIUSA. mmecoenhyl Sa. AGE -LaIa 30h0ay UNDER YEAR UNDER DAY EDATE OF PATH IMomd Oav Deaa Grand Island, NE. IY'YI 83 Ell T = D ]. SOCIAL EFCUiITV NJ V BCR en PLACE OF DEATH 506 -16 -2558 HOSPITAL ❑ Ineauenl OTHER ❑ Nugng lI,, ❑ ER OWPalkm IN Residence 8b FACILITY Name III See m,Melbn. gave I., ane numbed Home: 1960 West One R. Road ❑ DOA ❑ oma,,,y „ ",. ._._ be CITY TOWN OR LOCATION OF DEATH &L IN90E CITY LIMITS 9e COUNTY OF REATN - Grand Island ❑ ® Hall yep Nn By RESIDENCE -GTATE 90 COUNTY 9C CITY_ TOWN OR LOCATION 9tl STPEETANDNUMBEN jem1EdO2m CYSm 9e INSIULCDY11611T5 Nebraska Hall Grand Island 1960 West One R. Rd ❑ Yea Nn 10. RACE K.g.,Wh1m Blank. AmWoanlNian. 11. ANCESTRYIeg. IM Man. Mean Garman,eel d 13 NAME OF SPOUSE III wile. Pre make, name) at I ISooeTyl White I$geClnl American ❑ NEVER R DIVORCED MARIED Betty Ann Sinsel Y _ I<a USUAL IX'6UPATION lGVe kmOd nwk [bne W,ilg mns! 1A0 KIND OF BUSINESS INDUSTRY t5 EDUCPTION ISpeClly only NgM9gra0e conlplele0l M N Ekmaryazy a Saconea', ro 121 Od1e,o II a IT , 1L 18 FATHER NAME FIRST MIDDLE LAST P MOTHER FIRST MIDDLE MAIDEN SURNAME Theodore Yankten Lena Blockowitz 18 WAS DECEASED EVER IN JS. ARMED FORCESY I9a INFOFMANT -NAME -1 a�0 Yes: WW IIYeag'1 -5 9 413 -5 -1945 Betty Yankten 190 INFORMANT MAILING ADDRESS IS MELT OR IT F.0 NO CITY OR TOWN STATE. ZIPI 1960 West One R. Road, Grand Island, NE. 68801 EMB LMER- $IGNATUREb LICENSE NO. 21a 'ASTH00 of O15PC51T10\ 121p DATE 121c CCMCTCHY DH CHLMnI CHV NAMC FRUna1 ❑Pem_II June 26, 200 Grand Island Cemetery 22a FUNERAL ME -NAME I210 CEMETERY OR CHLMAIURY LOCPHON CITY OR TOWN STAIF Apfel- Butler - Geddes ❑ mmam, ❑Dna11n. Grand Island, NE. 22E FUNERAL HOME ADDRESS !STREET OR R FD NO CITY OR TOWN. STATE. ZIP) 1123 West Second, Grand Island, NE. 68801 23 IMMEDIATE CAUSE (ENTER ONLY ONE 2^ 11,1E PER LINE FOR al III AND'cll In1ery oel sel a• . I PA'T I a Natural causes unknown O NI -. Co Tel OTHER SIGNIFICANT CONDITIONS- Cantons contralamg to The doom bu nlmlale0 PART IF FEMALE WAR TITEREP 1125 WASCASE HEFLRHED IOMEDICAI PART �ADTOPGY P R UNANLY M1 4E PAST 317TATH9 EXAMINER pR OTNT' II A9 0 5U ve ❑ No ❑ Yes ❑,. NO ® Y Yv C 2r8n� 26m pq TEOF BAIURY /Ma Day Yl r2F.r. HJUR OF INJLgY 286 DESIR BaeIgW INJ H'+OCCJnRCO L I a,cT L 1 ilnnep M r� SacIU I� P_ Jig 2fie. INJURYAT WORK 281 PLACE! FINJLRV- qt11 L11 SARI Io" 13•iq UOUATION STREETORRFD. NO IIa OFTOWN i11 ' Qoe gnoota,, me m, gal �l Iga mn Yas ❑ N. ❑ )> C D N CD /DaiF (, TTT�TTTT11 i _ Vi .. _ Kam` zTU Dr LE SIGNED "a Cav Y,. 2)c IML OF DEATH 1 a Ta NE r 1 anp P- roaouNCeD DEAD I� Day, v.; 2oa. PHONGUNL I _ D_AD l Lin I Vim_ 120e H2M M June 2 ° a 27J CitebentelmV,,iowerge . 0eolhov1111a1111e1me 4a.. n—Y1luelol1a, On 1- base pl exam nal pr. anU nv sl gal011 Amy oPnon tledm ottullend the 1 mc. cale ann n au n me .a IFae Ia ea _ /��-, �Sglawe anP TMeI� I$ ane The T M 131 NAME AND ADDRESS OF CERTIFIER I PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY! ITp,,Rmp Ci J V y + rn ITT RC N !; f D W CIO � c `� > F--+ W .... W Co --Q CM WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND MMKNSERVICES SYSTEM, IT CERTIFIES THE BEL0 W TO BE A TRUE COPY OF THE ORIGINALRPCOM ON F_ IEEYAM THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS: SECrm vmbH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE �OppF ISSUANCE qq 200208717 ANLETS R UUL 5 2002 ASSISTANT STATE REGISTRAR LINCOLN, NEBRASKA HEALTH AND7A)MAN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERIW ES FM CE_A5&si{7PPORT VITAL STATISTICS CERTIFICATE OF DEATH 02 07567 II DLCEDE17 - 1:A'!E FIRST MIDDLE IPST JC% 3. DATEOFDFATH Earl Theodore Yankten Male June 21, 2002 i ODYANDSTATEOFOIRTH Ilmo,vIUSA. mmecoenhyl Sa. AGE -LaIa 30h0ay UNDER YEAR UNDER DAY EDATE OF PATH IMomd Oav Deaa Grand Island, NE. IY'YI 83 December 15, 1918 0 n,oG I DAYS 5CHOURS MIN$ ]. SOCIAL EFCUiITV NJ V BCR en PLACE OF DEATH 506 -16 -2558 HOSPITAL ❑ Ineauenl OTHER ❑ Nugng lI,, ❑ ER OWPalkm IN Residence 8b FACILITY Name III See m,Melbn. gave I., ane numbed Home: 1960 West One R. Road ❑ DOA ❑ oma,,,y „ ",. ._._ be CITY TOWN OR LOCATION OF DEATH &L IN90E CITY LIMITS 9e COUNTY OF REATN - Grand Island ❑ ® Hall yep Nn By RESIDENCE -GTATE 90 COUNTY 9C CITY_ TOWN OR LOCATION 9tl STPEETANDNUMBEN jem1EdO2m CYSm 9e INSIULCDY11611T5 Nebraska Hall Grand Island 1960 West One R. Rd ❑ Yea Nn 10. RACE K.g.,Wh1m Blank. AmWoanlNian. 11. ANCESTRYIeg. IM Man. Mean Garman,eel 12a MggRED ❑WIDOWED 13 NAME OF SPOUSE III wile. Pre make, name) at I ISooeTyl White I$geClnl American ❑ NEVER R DIVORCED MARIED Betty Ann Sinsel Y _ I<a USUAL IX'6UPATION lGVe kmOd nwk [bne W,ilg mns! 1A0 KIND OF BUSINESS INDUSTRY t5 EDUCPTION ISpeClly only NgM9gra0e conlplele0l d wwkmg Ills, even N,eUleR, Farmer Agriculture Ekmaryazy a Saconea', ro 121 Od1e,o II a IT , 1L 18 FATHER NAME FIRST MIDDLE LAST P MOTHER FIRST MIDDLE MAIDEN SURNAME Theodore Yankten Lena Blockowitz 18 WAS DECEASED EVER IN JS. ARMED FORCESY I9a INFOFMANT -NAME -1 a�0 Yes: WW IIYeag'1 -5 9 413 -5 -1945 Betty Yankten 190 INFORMANT MAILING ADDRESS IS MELT OR IT F.0 NO CITY OR TOWN STATE. ZIPI 1960 West One R. Road, Grand Island, NE. 68801 EMB LMER- $IGNATUREb LICENSE NO. 21a 'ASTH00 of O15PC51T10\ 121p DATE 121c CCMCTCHY DH CHLMnI CHV NAMC FRUna1 ❑Pem_II June 26, 200 Grand Island Cemetery 22a FUNERAL ME -NAME I210 CEMETERY OR CHLMAIURY LOCPHON CITY OR TOWN STAIF Apfel- Butler - Geddes ❑ mmam, ❑Dna11n. Grand Island, NE. 22E FUNERAL HOME ADDRESS !STREET OR R FD NO CITY OR TOWN. STATE. ZIP) 1123 West Second, Grand Island, NE. 68801 23 IMMEDIATE CAUSE (ENTER ONLY ONE 2^ 11,1E PER LINE FOR al III AND'cll In1ery oel sel a• . I PA'T I a Natural causes unknown _ DUE T0. OR AS A CONSEQUENCE OF lmaerval bemreen Ansel am eea¢ NI DDF TO nn ACaro 111. -D -2 OF Tel OTHER SIGNIFICANT CONDITIONS- Cantons contralamg to The doom bu nlmlale0 PART IF FEMALE WAR TITEREP 1125 WASCASE HEFLRHED IOMEDICAI PART �ADTOPGY P R UNANLY M1 4E PAST 317TATH9 EXAMINER pR OTNT' II A9 0 5U ve ❑ No ❑ Yes ❑,. NO ® Y Yv C 2r8n� 26m pq TEOF BAIURY /Ma Day Yl r2F.r. HJUR OF INJLgY 286 DESIR BaeIgW INJ H'+OCCJnRCO L I a,cT L 1 ilnnep M r� SacIU I� P_ Jig 2fie. INJURYAT WORK 281 PLACE! FINJLRV- qt11 L11 SARI Io" 13•iq UOUATION STREETORRFD. NO IIa OFTOWN i11 ' Qoe gnoota,, me m, gal �l Iga mn Yas ❑ N. ❑ 2le Divk of DEATF IMO. My v,) 2Fa 51CNED IIAv Oev n l let gML C1 UYATH /DaiF (, TTT�TTTT11 i _ Vi .. _ Kam` zTU Dr LE SIGNED "a Cav Y,. 2)c IML OF DEATH 1 a Ta NE r 1 anp P- roaouNCeD DEAD I� Day, v.; 2oa. PHONGUNL I _ D_AD l Lin I Vim_ 120e H2M M June 2 ° a 27J CitebentelmV,,iowerge . 0eolhov1111a1111e1me 4a.. n—Y1luelol1a, On 1- base pl exam nal pr. anU nv sl gal011 Amy oPnon tledm ottullend the 1 mc. cale ann n au n me .a IFae Ia ea _ /��-, �Sglawe anP TMeI� I$ ane The T _`_._1u_I~ . TOBACCO USE CUNIRIBUTE TO THE OEALH, ]O.al!ASORGAN OR TISSUE DONATION BEEN CONSIOFREDV "300 CONSENT GRArviED'� ❑ YES ❑ NO ® UNKNOWN ❑ vES IN NO ❑ YES NO 131 NAME AND ADDRESS OF CERTIFIER I PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY! ITp,,Rmp IDep L Gardient, HCSO, 131 � Locugt o Grand Island, NE 68801 /i-I 0 R / 1320 oAI11TRDH1H1GIbI lA. MAY or SO