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200210182
<br />STATE OF NEBRAS"—DEPARTMENT OF HEALTH -10sr ,A
<br />BUREAU OF VITAL STATISTICS '�{/+ J
<br />CERTIFICATE OF DEATH
<br />DECEDENT —NAME FI0.5i MIDDIE IAA,
<br />SIR
<br />DATE OF DEATH (N Dey, Y,
<br />E
<br />female
<br />March 11 1
<br />1_
<br />].
<br />J.
<br />RACE— (e.q.. Whila.pl°d, Amerimn CAIGIN(DESCENi Ia If, Iblia M-1—
<br />AGE —bn II UNDER I YEAR UNDER DAY DATE Of BIRTH IMF, Oay. Y,I
<br />°v
<br />Intliagel°J( SLI.Ff') Germeryere I Spea(Y lL(Y.l
<br />MO S.: DAYS XOURS MINS.
<br />I. �. 5.
<br />60. 4 Bb. fe. ). 11 -1G -1 24
<br />CITY AND 01Of BIRTN 'If "al I, LLSA., CIJIEEN
<br />OI WXAI COUNTRY
<br />MA0.RI D,NEVERMARRIED.
<br />NAME Of SPOUSE(( /vi /s. give maiden nomel
<br />'.."I
<br />WIDOWED, DI VORCED(Sp,,i /y)
<br />Ashton, Iowa
<br />' d
<br />Daniel M. Luton
<br />I ,,
<br />III,
<br />I,.
<br />SOCIAL SECURITY NUMBER
<br />USVAIOLIUIADCN( Ow. M PII e/w Ldone dIlm,p— RIND Of BU51N III OR INDUSTRY
<br />1O TI.I.IATX
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<br />q'ir Religion
<br />Ix. 48 20 2010,,,.
<br />ecretary 1]b
<br />„e. n rq Dt or
<br />CIIY.iOWNOR IOCATION Of OfATX INSIDECITYlIMR3
<br />X IIiAx OR OiHfR IN$LITVTION— Name P(nalin eilM1er.
<br />O. OI IN]L In
<br />(Spe.ily
<br />Yemr Nel
<br />pivs noel end numbnl
<br />M.
<br />nr'jEiner.Rm.(]p
<br />„b. Tincnln Nchraska
<br />Le. yes
<br />—
<br />14.
<br />RESIDENCE —STATE
<br />COUNtt
<br />CI IOWNOR LOCATION
<br />STREET AND NUMBED
<br />INSIDE CITY I... TS
<br />($PeeilY Y., °r Ne)
<br />15e.
<br />ISb. Hall
<br />ISC
<br />15d. 2 4 Ave
<br />15e. YAQ
<br />PATHE0. —NAME III— MIDDIE 45t
<br />MOWER —M (DEN NAME fIP51 MIDDIE
<br />WAS DECE VER IN IL S. ARME D —R-R,
<br />ASED E
<br />INPURMANI— NAME— REIAx10NSHII— SAILING ADDRESS MILE. OB RID. NO.. CITY OB TUWN 5141, zn1
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<br />+. HuSiDan -i 24 4 N G I. Nebraska 6.,801
<br />BURIAL, Crema,iary Removal DATE
<br />CEMET E PY OP CREMATORY — NAME
<br />LOCATION CITY OR TOWN STATE
<br />Jj_ -14 -79
<br />xD<. Calvar - Westlawn
<br />]Od. Grand Island Nebr.
<br />BA fR— $IONS! CENSE NO.
<br />IUNERAI HOME —NAME AND ADDRESS (STREET OR RED. NO., CITY OR TOWN, STATE, ZIP)
<br />�~
<br />F. H. Grand Island. Nebr.
<br />,
<br />xx.L'v' st rderman
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<br />M°., Oay Y ) NOUR OF DEATX
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<br />DA (M Dey, Yr
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<br />EWONOVNCED
<br />X (�M� Yrl
<br />DEAD
<br />/°(. /9,vG
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<br />24d,
<br />NAME AND
<br />' x5 �D, RESwf CE0.TH_IEP - IPh XY SICaIAfNM, CK O ROn NE RS D 1NY51CIAN OR Co Y A FNE . 1
<br />E/ -4Eo L.PEE /M GS.ia�
<br />{ PEGIS[RA0. DATE RECEIVED BY 0.EGISiPM (Me., Dey, Yr.1
<br />xB (]IP. °:...,► """""�""� - xEB. MAR 14 1979
<br />IS IMMEDIA[E CAUSE (fN R ONLY ONE /CAUSE IFR Nj }OP fol, fbl. ANO (c)) unv I.I. °m. °n 1 RI
<br />I �Rr �ir21 I/'C[ 'irl S:- c'. +Trw uYC .3 ; 3S 0124 z0 .vl I w
<br />DUFiO, R—A I— U :
<br />1„ayxa k, I ji�k P[.crru e_ 2.�OXa,�j��3 /9�
<br />DUE TO, OR AS A CONSEQUENCE Of
<br />FART OXEf SGNECANi CONDi ON3 C°"drem mmr bw"I I PI Ew "m.c.a 4NAN T wSiNEPEA AUTOPSY MS, IS, REFIRE
<br />OTHER MEDICAL
<br />II PAIi]IbNEMSi I, IM ART lSP.� /Y HER NOOONN
<br />m ❑NNp ❑ x8. x1. NO
<br />COOENi.SWCOEN EOi NN0.Y (M°..0°Y. vr.l NON OF WARY
<br />DESCRIBE FLOWNID0.Y OCCURRED
<br />O I NDIN4INV[Si c4 oN[ISp.r�(yl
<br />]OaF ]06. ]Oe. M JOd.
<br />l" m my 0' ,"10111 O N.. CITY 00. "WN 34E
<br />SIR"" Y.r N .bv d" 0.- 111 -1
<br />JO
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />STATE DEPARTMENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br />A TRUE .COPY OF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />DEPARTMENT. OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH
<br />IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. ��
<br />C/ -2 plf�e2ll
<br />DIRECTOR OF VITAL STATISTICS AND ASSISTANT_5_TA2'E REGISTRAR
<br />LINCOLN, NEBRASKA ISSUed April 25, 1979
<br />
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