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<br />STATE. OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUFPART
<br />200505904 VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />1 Dr(.F.DFNT NAME FIR51 •.T..... - "- MUDIF ,•__ —._ IASl '�'•'�� -- 2 SFX 3 DAIEDF eA1H IAkM+HI Do, V.1
<br />Raym_ ond _Arthur _ Baker Male August 4, 2001
<br />I CIfYANDS1ATFOf ti1HIH JHnoln+f /SA n n+n cnunpyl •��'_._.....__._._ -- 5a AOF Lx91 Birlhdey 11NUER1 YEAR UNDER DX 8 gAlE OF GIRTH IAkvtlI. DIY /'earl
<br />IV••il 51+ M( DAY$ SC I1011q$ MIN,
<br />Johnstown , Nebraska 82 _.�___....._.� May 9_, 1919
<br />- -
<br />7 ftnf'IAI. SFCUATIY NIIMRFR Aa PLACE OF OFAIH
<br />712 -09 --4269 HOSPITAL L, Ir+p.lev OtHtn N— q-I-
<br />Rh rnr•rl,Ity. Nome lHnrvxr•nhmrm. giyp .'tool nrnl FR Ou,pnUnrd (� R.e,denre
<br />St. Francis Medical Center (_� nnA [] Gxn•,Sr�rror
<br />fir CITY IOWNORLOCANONOFDEAIII
<br />Grand Island
<br />9- RE SIUENCE •STATE 9h COI IN T --- -� - - --
<br />Nebraska Hall
<br />10 RACE Ieg. Wh -lp 13h,a AmP.u•An x,dr,,n 11 ANCEST RY Ir.y
<br />Fir.I fso -10 White
<br />IIa USLIAL OCCUPATION lG:vP 4iry nl xnrh 11onp dlrrnq mrtl _._. —__
<br />of "'A'"9 I+lp, "e I 'etrre'dl
<br />Retired Real Estate Agent
<br />16 FATHER - NAME — -FIRgl Mini 'llF
<br />Robert A.
<br />INSIDE Cl I LIMITS
<br />Yes N Nn LJ
<br />Grand Island
<br />in, Mr•rcAnGerman. elr.1 12 rQ�MgpgIED
<br />American �J NEVER
<br />r4h KIND (7F BUSINESS INDUIRTRY
<br />[teal Estate
<br />IASt '� 17 MO7 HER��
<br />Hall
<br />9d SIF1EEl ANONIJMIoli ikrrNrrrvp 1p Cr.rrl 9e IN$Ir +1 "•�i. :.
<br />102_E. 19th St. 68801 N L.'
<br />1 WI70*E1.1 11 NAME OF SPOUSE. to-to a" miMMn rrAmxr�•
<br />F _Bette _Jane Trapp
<br />15 EDUCAI ION (SP C.rly only M 40 grade cornP4 I
<br />11 n
<br />Elpm i ge+p,dr �r Qq
<br />— f"���i l7 ae ,21 CWkpe '
<br />Baker Laural H.
<br />rx W S DECEASED EVEN IN US ARMFO FORCF:S7 19a INFORMANI - NAMF
<br />'Yes -, rn unk 1 I 111 yn9 grvo w ,and dplr.$ of 6rrvirae)
<br />Yes �L Dates Unknown Bette Baker
<br />19h INFORMA—NT MA it IN('Xi )ORFSSW 1SiNFEI Oil Ft 11 Ni. FTY OR TOWN S'AIF 71-'1
<br />102 E. 19th St., Grand Island, Nebraska 68801
<br />7q FM1 R SIIiNA1N11F IIrE FNCr T••••Yi� ..._.. .... 71- M!'tHpO OF '"' - --
<br />MIDUI.F
<br />Wolfe
<br />i /
<br />) 019P08111DN
<br />21h 0AtIF JJ ce,CFMyt:RFOn C• MAIORY Me
<br />q �iemor art Park
<br />Aug. 9, 200_1 Crematory
<br />2TA i UTr I A 1�1 . NA
<br />Livingston- Sondermann
<br />F.H.
<br />i
<br />),:rMnAVp ❑I «N,AN,,,
<br />21d CFME1'ERV ON CHFMA I Oily LOCAL ION _ -� Cl TV OR TOWN e14"
<br />r--.-A T 1 .4
<br />Ne
<br />221, FUNERAL NOME AON( +F 55 IcInEET C7R AFq NO IT
<br />CY I)n s an MOWN SIAIE. ZIP' � - - -T^" `T' —_�_
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4_050
<br />23 IMMEDIAI'F f:AUSf '�'• ... _.. IFN I FN ONLY ONE CAUSE PER LINE FOR 1.11 1111. ANp IC9 _.,•_._...�_r.,
<br />�PARI
<br />Fh ►.L4M�M 4 N
<br />lal
<br />O1.1F• TO OR AS A CI.om iEOUENCE OF '�•���� - - -'T'
<br />�'-
<br />ICI
<br />OCHER SIGNIFICANT CONDO IONS Cmdiunng rdnlnhulinq In ma drain but n01 relined PAHI IIIIF FEMALE. WAS THERE A Tn A
<br />PA1f11 PREGNANCY IN THE PAST 3 MONTHSIT �..r
<br />U!I}�niu.
<br />A 1
<br />_ ( gog 0 541 Yes No Yea
<br />26a 26b DATE OF INJURY (Md. DeV. Yr) 26c HOLIA OF INJURY 26d. DESCAIgE HOW INJURY OCCURRED
<br />Arr nleM � UndPlw.mmrd M
<br />❑ Suicide 0 Pp idmo 26e IN.1tfF1Y AT WORK" 761 PkAC f OF INN.IUR'I %Al hoot, 1pnn• 91•ee1. today �TSq�I OC`AiION
<br />Y.. ❑ ❑ O iCR ,rrlMin 91� spec 6' I
<br />Hur +nude Invasbgmnn v Hu
<br />770 DATE OF OEATH )AkI. IUV Vr/
<br />SJI T7h pAIE 31 NFD lMu.••TNIY Yi) 27, �IIMF OF OFAIH
<br />I k sal -v-
<br />27d To 'he boil W my knowledge. d— oh grru -rod at the f ma. do,, aid Nana end due to'I+o
<br />una191 .'Tiled
<br />ISI nahaa and Tale � Vrr ` �"�. !�•
<br />29 DID TOBACCO USE CONI 111BUTE YO THE UEA THY _ TOa I +AS OF*AN O
<br />}r [] YE5 NO 1:1 UNKNOWN
<br />31 NAME AND ADnRPSSOf CERTIFIEN'PHYSICIAN, CORONER S PHYSICIAN nR IWIMTV ATIATI
<br />kflk•�& 11-1 4 YT h K . VY10 tig
<br />Va REGl5T
<br />FOR VITAL STATISTICS USE ONLY
<br />I Mprval , MeN a , ,,
<br />1
<br />I haervar balYreae area a,.,. _:
<br />I Ir,aFrvsl benreen dn9e1 a^ , :. +
<br />I
<br />I _ _
<br />' �WASCASEREpERRFt)1�"i�' „'_ �
<br />EXAMINEROR CORONFu'
<br />T
<br />No Y. I I N;. 0
<br />STREEI ON RFD No CITY OR TOWN
<br />TAM 11m, Y• 1 128b TIME OF DEATH
<br />2ec PRONOUNCED OF AD /Ae+ Dar, Vr.1 Zed. PRONOUNCED DEAD
<br />M V -
<br />°u 26e On n,e baste oI e.am�nn,wn and a Invesn anon. h m
<br />11 a 9 Y oP'n4n daaar grc.nae w
<br />the bmA, dpro and deco nrM due ro 9,e CAwalsl elated
<br />TISSUE DONATION �BE�Fjf� CONSIDERED' 304 WAS CONSENT GRANTED?
<br />11 YES I7C 1 NO i El YES 2� NO
<br />M
<br />As (-L'21.1-0 Ic_
<br />JRb DATE FILED BY REGISTRAR IAN., Day. Yr) '•
<br />Place....................... A ................................ B ................................ G ... .................. ........ D ................................ E ... .. ... ........................ Part II.......... ............ TMV
<br />Reject
<br />.'� hn•rx w11h .Or I” � •rryrrrd parer
<br />I hereby certify this to be a true and correct cagy of the original
<br />filed with the State of Nebraska
<br />Y .C'
<br />Signed in my presence this f/1 d of
<br />Notary Public
<br />TERRY L LOSCHEN
<br />r °` "F" MY COMMISSION EXPIRE=S
<br />*= fRA- «'
<br />May 2, 2006
<br />
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