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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOR94W FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISI4=WPQ_N, -NIGH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _ <br />DATE OF ISSUANCE <br />JAM EY S.' COQPER <br />APR 14 2005 200503418 <br />a �s alvr ra I E ®�srr�a <br />LINCOLN, NEBRASKA HEALTH ANO HUMAIII.�EAMM SAS M <br />PHS-7BB V( S) RICV. 4 -57 STATE OF 1 EBIL "K1 -_ <br />DEAR OF PUBLIC HEALTH. DEPARTYEN? of m,L� 1418 <br />s>t�vcATxox AND w>r�t.FAxtt Bare" of Vital etathoU I1 -.. <br />BIRTH xo- 126_._ - -... CERTIFICATE OF DEATH ffirATZ rau >)foM__ -. -' :."...-------- �•----- _...._ ......... .. <br />1. PLO= " M[ATII Jr - <br />�6-1 <br />_ <br />a. COUNTY -' <br />Han <br />a. STATE •. COURT' <br />b. CITY. TOWN. OR LOCATION <br />Grand Island <br />c. LENGTH OF STAY IN ib <br />I <br />c. CITY. TOWN. Celt LOCATM <br />Grand island <br />d. NAME OF (it no iN keepilal. on shod eddrm) <br />d. STREET ADOAESS <br />HOSPITAL OR <br />josTITUTION Ste � � <br />516 R T�,� <br />M <br />t. IS PLACE OF DEATH INSIDE CITY LIMITS? YES r3 MA <br />C. IS REST ENCE INSIDE CITY LIMITS? <br />6 <br />=a <br />m <br />rn <br />n <br />� <br />n <br />n <br />N <br />.� <br />MATH Dec. 1 1 <br />rn <br />tip RACE <br />7. MARRIED NEVER MARRIED <br />B- DATE OF BHtTH <br />!. AGE (IH rcre <br />c <br />n <br />= <br />� 309 ' 896 <br />c <br />� <br />° <br />.lo <br />Le <br />WIDOWED DIVORCED <br />d <br />� <br />10e. USUAL OCCUPATION (Gift kind kfWork sate <br />106. KIND OF SUSNIESS OR NIOUSTRY <br />fV <br />N <br />im sled of Working life, emu if rdirel) <br />_ <br />,},� <br />0011' t Nab, <br />r <br />�• <br />_ <br />M <br />O <br />19 <br />15. WAS DECEASED EVER HI U. S. ARMED FORCES7 If. SOC1A1. SECURITY RO. <br />r7'i <br />> <br />T-08 i I r <br />W.jfi&gNX". <br />Hass33s: XWmeang Gm d heir. <br />m <br />12. C WW OW S"1rft [Enter wdw *w cwAw Per lies Aa (s). (e). and (0.1 <br />J <br />'*1 <br />PART 1. DEATH WAS CAUSED BY: <br />cri <br />IMMEDIATE CAUSE (a) <br />Ca+�dit(sat. tJ41IP. DUE To (b) w <br />IPAid few r:' !o <br />@&we cane 4). <br />the <br />t itK cam" tail. DUE TO (c) <br />PART H- arHER SICA{ XAM COIICi •IONS CONrIBIBMW TD DEATH BUT NOT TO THE TERMRML DISEASE COIbITmw C�In a POT go) <br />4 <br />M <br />20s. ACCIDENT SUICIDE HOMIC'DE <br />0 <br />❑ ❑ ❑ <br />U <br />7 <br />Sk. TIME OF Hour Month. Dfr. Yew <br />CD <br />� <br />00 <br />o <br />A• m <br />20d. INJURY OCCURRED <br />2tk, PLACE OF INJURY (c. P• in or d+ellt beat, <br />f bw. de.) <br />2W.. CITY. TOWN. OR LOCATR7M COUNTY STATE <br />13 <br />r- 1 <br />CA) <br />LIP � <br />WORK AT WORK <br />21. I attended the d a.aa.d from — to &Ad%Vie sae � afire On " <br />Death occutrw at AAtt m on the date stated shire; and to the hart of sky kae mwledp, hom the at 4som otarM_ <br />2is. BIWMATWIE ( ar lMic) <br />22lb. A . AVk. tlKFE SMir� <br />234- NUIl1AL. CJIE"TION. Z*- DATE NAME OF CEMETERY OR CREMAT <br />x3t. TM (cwmB ftwx. or cow") (J tMt3 <br />RE fA SpectIrl <br />M. DATE RECD BY REi RAR 25. REGISTRAR'S SM■NA <br />ILAI <br />A. NAME OF NORTUAIIY Add <br />00 <br />qw Livi Ohm" 3blowdS I$*i <br />CX) <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOR94W FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISI4=WPQ_N, -NIGH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _ <br />DATE OF ISSUANCE <br />JAM EY S.' COQPER <br />APR 14 2005 200503418 <br />a �s alvr ra I E ®�srr�a <br />LINCOLN, NEBRASKA HEALTH ANO HUMAIII.�EAMM SAS M <br />PHS-7BB V( S) RICV. 4 -57 STATE OF 1 EBIL "K1 -_ <br />DEAR OF PUBLIC HEALTH. DEPARTYEN? of m,L� 1418 <br />s>t�vcATxox AND w>r�t.FAxtt Bare" of Vital etathoU I1 -.. <br />BIRTH xo- 126_._ - -... CERTIFICATE OF DEATH ffirATZ rau >)foM__ -. -' :."...-------- �•----- _...._ ......... .. <br />1. PLO= " M[ATII Jr - <br />2 USUAL BWtl 1112 E (1►llnv ea..rr }rc. !li rM4Mwr Rr+tMr hrP. r adeirlrw) <br />_ <br />a. COUNTY -' <br />Han <br />a. STATE •. COURT' <br />b. CITY. TOWN. OR LOCATION <br />Grand Island <br />c. LENGTH OF STAY IN ib <br />I <br />c. CITY. TOWN. Celt LOCATM <br />Grand island <br />d. NAME OF (it no iN keepilal. on shod eddrm) <br />d. STREET ADOAESS <br />HOSPITAL OR <br />josTITUTION Ste � � <br />516 R T�,� <br />M <br />t. IS PLACE OF DEATH INSIDE CITY LIMITS? YES r3 MA <br />C. IS REST ENCE INSIDE CITY LIMITS? <br />I. FAIM RESIBEMCEr YE! <br />I <br />=a <br />ND <br />3. MARIE Yi Fist L4W <br />4. DATE AIew�1 Do yew <br />N <br />(7�jpe t.�tMfiwt <br />Print) �QT wJ4. lim Nlm2n <br />MATH Dec. 1 1 <br />5. % <br />tip RACE <br />7. MARRIED NEVER MARRIED <br />B- DATE OF BHtTH <br />!. AGE (IH rcre <br />d IsaER I Ifm tsK NNt <br />� 309 ' 896 <br />""w? <br />Mwlr <br />tarn 1rw/w <br />.lo <br />Le <br />WIDOWED DIVORCED <br />10e. USUAL OCCUPATION (Gift kind kfWork sate <br />106. KIND OF SUSNIESS OR NIOUSTRY <br />If, OWTMPLACE (Sate or fird►It mwltrv) <br />CR 41F ?NMI tIB UN I I <br />im sled of Working life, emu if rdirel) <br />,},� <br />0011' t Nab, <br />U. s. <br />134. FATHER'S NAME I3r.MOYHER'S MAIDEN MAW <br />M. NA— M_E�OFF+MUSAAAD OR WfFE <br />Ham � YA=on <br />15. WAS DECEASED EVER HI U. S. ARMED FORCES7 If. SOC1A1. SECURITY RO. <br />17. WFOO AMT Adbtal <br />(Y's. M. w rwknaw.) (If .d. firs ~ w delss K sr`scss) <br />T-08 i I r <br />W.jfi&gNX". <br />Hass33s: XWmeang Gm d heir. <br />m <br />12. C WW OW S"1rft [Enter wdw *w cwAw Per lies Aa (s). (e). and (0.1 <br />ISIfIRVAL I E►M1EE7I <br />PART 1. DEATH WAS CAUSED BY: <br />T Ap KATN <br />IMMEDIATE CAUSE (a) <br />Ca+�dit(sat. tJ41IP. DUE To (b) w <br />IPAid few r:' !o <br />@&we cane 4). <br />the <br />t itK cam" tail. DUE TO (c) <br />PART H- arHER SICA{ XAM COIICi •IONS CONrIBIBMW TD DEATH BUT NOT TO THE TERMRML DISEASE COIbITmw C�In a POT go) <br />4 <br />va no <br />20s. ACCIDENT SUICIDE HOMIC'DE <br />1ElliW, DESCRIBE HOW INJURY OCCURRED. (JW0 *slue alinjrrT in Pat I OF PNr,i lI of** 11.) <br />❑ ❑ ❑ <br />U <br />Sk. TIME OF Hour Month. Dfr. Yew <br />INJURY a. In. <br />o <br />A• m <br />20d. INJURY OCCURRED <br />2tk, PLACE OF INJURY (c. P• in or d+ellt beat, <br />f bw. de.) <br />2W.. CITY. TOWN. OR LOCATR7M COUNTY STATE <br />WHILE AT ❑ NOT WHILE ❑ <br />�� irT. +hut. e�oe <br />WORK AT WORK <br />21. I attended the d a.aa.d from — to &Ad%Vie sae � afire On " <br />Death occutrw at AAtt m on the date stated shire; and to the hart of sky kae mwledp, hom the at 4som otarM_ <br />2is. BIWMATWIE ( ar lMic) <br />22lb. A . AVk. tlKFE SMir� <br />234- NUIl1AL. CJIE"TION. Z*- DATE NAME OF CEMETERY OR CREMAT <br />x3t. TM (cwmB ftwx. or cow") (J tMt3 <br />RE fA SpectIrl <br />M. DATE RECD BY REi RAR 25. REGISTRAR'S SM■NA <br />ILAI <br />A. NAME OF NORTUAIIY Add <br />qw Livi Ohm" 3blowdS I$*i <br />a mom. ITT <br />The Wsaterly 20 feet of Lot . 7 and all of Lot b.. Block 100, O,r1<UZOAd. Addition, <br />City of Grand Island, Hall C*untq, Nebraska. . <br />