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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 RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC��C_ T WJM!PKI$
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE =.
<br />MAY 2 5 2005 200 5 o al 329 ASSST4NTfiAt� ;�T,tR -=
<br />LINCOLN, NEBRASKA HEALTH AND *MAN $ERVIC�S'YSTEM_
<br />STATE OF NURAw_OEPw MENT of NEALT1t ` 00713
<br />BUK U OF VITAL STATISTICS -- _
<br />CERTIFICATE OF DEATH
<br />DECEDENT -NAME ART MI LA X DATE -
<br />(Mo., Day, Yr.J
<br />.
<br />I. Ha&vea tee BO a 12. !1 e 13. Ian 5. 1 Q7 Q
<br />W ife, Black. A icciit ORIGIN /DESCENT(e.g., Malian. Mexican, I A491E -I" Ilinhday UNDERIYEARI UNIDERIDAf DATE OF 61RTH (Ma., Day, 7'r.)
<br />Indian, eki(Specdfy) German, Ne.)(Specify) a (Yn.) Mo$. DAYS HOURS; MINS.
<br />4. ._- - ... !v'it.t►if.0 66 > ] iI .
<br />AND STATE OF BIRTH (Of not in U.S.A., CITIZEN OF WHAT COUNTRY MARRIED, NEVER MARRIED, NAME OF SPOUSE (If wile, give maiden name)
<br />name country) WIDOWED, DIVORCEDfSpeeify)
<br />SOCIAL SECURITY NUMBER USUAL OCCUPATION (Give kind of work done during most KIND OF BUSINESS OR INDUSTRY JCOUNTYOFDEATH
<br />of working life, own if retired)
<br />iz._.506 -14 -0236 13a - -- -tJL ' 1 1131'. / 14a.
<br />CITY, TOWN OR LOCATION OF DEATH INSIDE CITY LIMITS HOSPITAL OR OTHER INSTITUTI - Name (If not in either, If NOSP. OR INST. iedit6m DOA,
<br />f v (Specify Yes or No) give street and number) Outpatient /lmet. Ret., Inpatient (Specitp
<br />14b. _( L, , d .5-atari 4 14e. Ue4 14d. 114,.
<br />RESIDENCE / -� STATE COUNTY CI , TOWN OR LOCATION STREET AND NUMBER INSIDE CITY LIMIT_
<br />130. nte:{Jk -.. 15b. Ha(.(. 1Se. Wood tur ISd. 1Sp!cify Yes or No.
<br />FATHER -NAME FI M LA MOTH R. N NAM FIR MIDDL rr LAST
<br />70 h
<br />WAS DECEASED EVER IN U.S. ARMED FO ES? INFORMANT- N - RELATIONSHIP- MAILING ADDRESS (STREET Oil R.F.D. NO., CITY OR TOWN, STATE, Zip)
<br />(Yes, no, w unk) (H real. give war clad dates of service)
<br />IB. - - - I ')O 2.. 1.943 -46 i 191ita ha&u ka 68883
<br />BURIAL; Crenwtion, RemO72%b. CEMETERY DR CREMATO -NAM LOCATION -CITY OR TOWN STATE
<br />200. 13UA'A1L.� y - �r_ 20c. 20d, nehaaAka
<br />EMBALMER- SIGNATURE A LICENSE NO. FUNERAL HOME -NAME AND ADDRESS (STREET Cris R -f.0, NO., CITY OR TOWN, STATE. IP)
<br />122. - -.68883
<br />TO best et my knowledge, ddOlYgiall0d at the ti daft and Plopia 60d 647 the On *a basis a1 examination andJrr inrretigptian, in my Spinier dsa h etxurred t»
<br />►) doteel- 9 _ z the timr, slaw aed Place and d. 1. he coure(ri staled.
<br />i y�st 22a.(Si pause and TiNe /.'� - 7 240. ($.g.o►rn and Tide) ■
<br />i DA NED(Mo., _Ya: NO DEATH _
<br />t-b y, r. DEATH
<br />r
<br />123c. rw x 24b. 24c. M. _
<br />DATE OF DD Q[EE���Iu,,TH (Mo., y, Yr.) S PRONOUNCED DEAD PRONOUNCED DEAD (Hour)
<br />-T� - (Mo.. Day, Yr.)
<br />23d. G -t._z_ ! . / / 4 M
<br />-..._
<br />NAME AND ADDRESS Of frE'llFIER ( HYSlCIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />%..
<br />25. Fred W. Harb M. n. Box 448 Cairn NE 68824 _
<br />REGISTRAR _ DA ECEIVEO BY EGI TRAR (Mo__ DayYr.)
<br />26a.(SWnaturel� 26
<br />.1 :xMEDIATI CAUiiE / V (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b) D (c)) Mewl betw�em eaet orrd death
<br />DUE TO, OR AS A CONSEQUENCE OF: )ti real bew
<br />hen onset and sl"
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval botweeo anlai cnd death
<br />IcT
<br />PART, OTHER SIGNIFICANT CONDITIONS- Conditis nuibuting to death but nor related PART III. IF IEMALE WAS THERE A AUTOPSY WAS CASE REFER TO MEDICAL
<br />PREGNANCY INTHFPAST3MONIHST (Sped Y or Hal EXAMINER NFR
<br />y / (Spi/y Yn
<br />eL: Yes ❑ No L 12e Q 1297
<br />ACCIDENTr'AKIDE, HOhuCIDE, UNDET , DALE Of INJURY (Mo., Dar. Y..) HOUR OF INJURY DESCRIES NOW INJURY OCCURRED
<br />OR PENDING INVESTIGATION. (Speri(y)
<br />_ 300.. 30b. 3fh. M 30d.
<br />INJURY AT WORK PLACE OF INJURY - M hems, farm, street, factory, LOCATION STREET OR R.F.D. No. CITY OR TOWN STATE
<br />(SPetar Yes w Ne) office building, eh. (Specify)
<br />Me. . .. - . . _. - -- 130f, 1309.
<br />
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