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WHEN THIS COPYCARMES 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 STATISTI_C-S= SA WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE - 'N
<br />AUG 11 2005 s0
<br />ASk -is
<br />LINCOLN, NEBRASKA 200508336 HEALTH ANA OMAN SER1d C1MtY9MM
<br />4 STATE OF NEBRASKA -- DEPARTMENT OF HEALTH `
<br />BUREAU OF VITAL STATISTICS i� Q 7 3 4 D
<br />CERTIFICATE OF DEATH — Y " �
<br />1. DECEDENT •NAME FIRST MIDOLE LAST 2. SEX 3. DATE of DEATH Aohmn pry yowl,
<br />Elmer Julius S iehs Male June 26, 1994
<br />/. CITY AND STATE OF BATH /11011 USA., ,ROry =r&y/ 5e. AGE - Lail S Imby UNDFR 1 V%AR UNG�R 0AY 6 DATE OF RMm vann . o y yowl
<br />Alda, Nebraska IY ;82 56 �«1s OMYS x. HouRS MN/S Mav 6, 1912
<br />e.. PLACE OF DEATH
<br />W8-09-40025 tOSwru [] kraal i,+
<br />6b FACX_rrYY� -Nmft ,-i,� 11,W MNaasm 9" straw" /1mb W) ❑ ER OI✓M.tli111
<br />Wedgewood Care Center ❑ DOA
<br />6[ C17Y TOWN OR LOCATON OF DFATH 6tl INSID=LMXT� OLMRY OF DEA1 Grand Island YOS Hall
<br />sk RESIDeNCF _ STA7F . on rru IuT� T
<br />Nebraska -- y �- Hall
<br />RACE - 1#9, IN NOR SI.CF AmAfK:YI /ldian. 11. ANCES
<br />sic lSplc.yl — . - _ ecWl
<br />Ift USUALOCCUPATION 4w *mddrpkdtkmdkmWmLv
<br />da"A11• Arm*?*
<br />MIWra.ght 51A
<br />16. FATHER -NAME FIRST MIDDLE
<br />Julius
<br />19 WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />(Y� ;&l
<br />unk) I (6Mq"wvanddaMSd$gSw el
<br />191) INFORMANT MAN NOD AfgIM -C C Ian
<br />OTHER ® NV%09 HGn.
<br />❑ Rwd�lt
<br />9C CITY. OWN Oii LOCATON 9d STREET AND NUMBER /AncludrlpZp Cmy! a. INSIDE CITY UMITS
<br />Grand Island 229 N. Boggs YeO� w ❑
<br />n. MO.101n. GMmbti 1lcl 12. ® MARRIED ❑ WIDOWED 13 NAME OF SPOUSE woo ow ffAdor. nlwy
<br />iab KWD OF SUSINESSMIWSTRY 15. EDUCATYXA IS—*
<br />Overhead Door �``�'K EwmwmvofS Q°w'°•121 o° (f,4 "5•`
<br />Mildred
<br />`rhesenvitz
<br />229 N. Boggs Grand Island, NE. 68803
<br />29. EMBALMER - SIGNATURE E LICEIISE No. VS. METHDDOF DISPOSITIDN 210, DATE 21C. CEMETERY OR CREMATORY IaAiaF
<br />I_ � -#/f� ® &- ❑ R.md.al June 29, 1994 Grand Island CA mete
<br />2?i FUNERAL HONE -NAME 21d CEMETERY OR CREMATORY LOCATION L17v OR 7OAMi STATE
<br />fel-- Butler- Geddes ❑ �'°""'°" tom- °°"°"°^ Island, Nebraska
<br />22b. FUIERIIL HOME ADDRESS ISTREET OR R.F.D. NO.. CITY OR TpNN, STATE.21P1 Grand
<br />1123 West second, Grand Island, NE, 68801
<br />N.IMEDIATE CAUSE I ER ONLY ONE CAUSE PER LINE FOR Is
<br />PART P�- •>A.vti� -c f,
<br />I 7i /f- ,-W w_ --/
<br />101
<br />III)
<br />TO. OR AS A CONSEC
<br />❑ A..N ❑ Undel.nnyletl
<br />[I &W-ft E) P.mng 126e. MUURY AT WORK 20 I
<br />HdmK:Itla
<br />Y. ❑ Np ❑
<br />270. DATE OF DEAR /Ab. OAy YrI
<br />6
<br />ION
<br />7K7N {/Alll IYM� I PART 1N IF FEMALE. WAS THERE A 24 AUTOPSY
<br />PREGNANCY IN THE PAST 3 A10NTHS+
<br />IAgn 10.5.1 Yet I/b Yes Nv
<br />2S6. DATE OF MLIURY (Ma, pay yr•J I 25c HOUR OF fUURY 126& DFSCRIBE HOW NIAIIRV OCCURRED
<br />� 1ae..al brallw 1� Aad xAln
<br />IIIinow bMlfell plael and (ISM
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<br />1
<br />a1 belwm arI Am omm
<br />i
<br />i
<br />25. WAS CASE I EEI To ME=ft
<br />MUkAMNER ^ OR CORONER?
<br />V0i 1 1 NO 12
<br />_ M
<br />(�.
<br />Wm- W011 tRCWY 269. LCX:ATKTN STREET OR R.F D. ND CITY OR TOWN STATE
<br />27D TE SIGNED 1W. Day Yr) 210 ,rm of DEATH
<br />ow bm � �qr.
<br />L27d u°1 .I IirdA k !L 604P unddtow MI D, 1*. 1/d 01- --m 6eIn ow
<br />DSACCO USE CONTFO UTE TO THE DEATH7 - 30a HAS C
<br />❑ YES ❑ No is UNKNOMMI
<br />AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR CM
<br />W. J. Lawton M. D. 2444
<br />'I32a
<br />ter:: 1
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<br />*ft. d1r 1m a 4 0 WWI q we ram sO1id.
<br />:�L.•_. W YyM
<br />TISSUE DONATION BEEN CONSIDERED, r30.b WAS CONSENT GRANTED1
<br />❑ YES m NO ❑ YES NO
<br />RNEY) !Typeapfty
<br />91ey, Grand Island, NE. 68803
<br />.. -- - . ..- .__.rI— DATERLFD8YWm1RA4 R*Lv r wo
<br />South Half of Lot 8, & all of Lots 9 and 10, Block 18, Packer & Barr's Second
<br />Addition to Grand Island, Hall County, Nebraska
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<br />WHEN THIS COPYCARMES 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 STATISTI_C-S= SA WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE - 'N
<br />AUG 11 2005 s0
<br />ASk -is
<br />LINCOLN, NEBRASKA 200508336 HEALTH ANA OMAN SER1d C1MtY9MM
<br />4 STATE OF NEBRASKA -- DEPARTMENT OF HEALTH `
<br />BUREAU OF VITAL STATISTICS i� Q 7 3 4 D
<br />CERTIFICATE OF DEATH — Y " �
<br />1. DECEDENT •NAME FIRST MIDOLE LAST 2. SEX 3. DATE of DEATH Aohmn pry yowl,
<br />Elmer Julius S iehs Male June 26, 1994
<br />/. CITY AND STATE OF BATH /11011 USA., ,ROry =r&y/ 5e. AGE - Lail S Imby UNDFR 1 V%AR UNG�R 0AY 6 DATE OF RMm vann . o y yowl
<br />Alda, Nebraska IY ;82 56 �«1s OMYS x. HouRS MN/S Mav 6, 1912
<br />e.. PLACE OF DEATH
<br />W8-09-40025 tOSwru [] kraal i,+
<br />6b FACX_rrYY� -Nmft ,-i,� 11,W MNaasm 9" straw" /1mb W) ❑ ER OI✓M.tli111
<br />Wedgewood Care Center ❑ DOA
<br />6[ C17Y TOWN OR LOCATON OF DFATH 6tl INSID=LMXT� OLMRY OF DEA1 Grand Island YOS Hall
<br />sk RESIDeNCF _ STA7F . on rru IuT� T
<br />Nebraska -- y �- Hall
<br />RACE - 1#9, IN NOR SI.CF AmAfK:YI /ldian. 11. ANCES
<br />sic lSplc.yl — . - _ ecWl
<br />Ift USUALOCCUPATION 4w *mddrpkdtkmdkmWmLv
<br />da"A11• Arm*?*
<br />MIWra.ght 51A
<br />16. FATHER -NAME FIRST MIDDLE
<br />Julius
<br />19 WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />(Y� ;&l
<br />unk) I (6Mq"wvanddaMSd$gSw el
<br />191) INFORMANT MAN NOD AfgIM -C C Ian
<br />OTHER ® NV%09 HGn.
<br />❑ Rwd�lt
<br />9C CITY. OWN Oii LOCATON 9d STREET AND NUMBER /AncludrlpZp Cmy! a. INSIDE CITY UMITS
<br />Grand Island 229 N. Boggs YeO� w ❑
<br />n. MO.101n. GMmbti 1lcl 12. ® MARRIED ❑ WIDOWED 13 NAME OF SPOUSE woo ow ffAdor. nlwy
<br />iab KWD OF SUSINESSMIWSTRY 15. EDUCATYXA IS—*
<br />Overhead Door �``�'K EwmwmvofS Q°w'°•121 o° (f,4 "5•`
<br />Mildred
<br />`rhesenvitz
<br />229 N. Boggs Grand Island, NE. 68803
<br />29. EMBALMER - SIGNATURE E LICEIISE No. VS. METHDDOF DISPOSITIDN 210, DATE 21C. CEMETERY OR CREMATORY IaAiaF
<br />I_ � -#/f� ® &- ❑ R.md.al June 29, 1994 Grand Island CA mete
<br />2?i FUNERAL HONE -NAME 21d CEMETERY OR CREMATORY LOCATION L17v OR 7OAMi STATE
<br />fel-- Butler- Geddes ❑ �'°""'°" tom- °°"°"°^ Island, Nebraska
<br />22b. FUIERIIL HOME ADDRESS ISTREET OR R.F.D. NO.. CITY OR TpNN, STATE.21P1 Grand
<br />1123 West second, Grand Island, NE, 68801
<br />N.IMEDIATE CAUSE I ER ONLY ONE CAUSE PER LINE FOR Is
<br />PART P�- •>A.vti� -c f,
<br />I 7i /f- ,-W w_ --/
<br />101
<br />III)
<br />TO. OR AS A CONSEC
<br />❑ A..N ❑ Undel.nnyletl
<br />[I &W-ft E) P.mng 126e. MUURY AT WORK 20 I
<br />HdmK:Itla
<br />Y. ❑ Np ❑
<br />270. DATE OF DEAR /Ab. OAy YrI
<br />6
<br />ION
<br />7K7N {/Alll IYM� I PART 1N IF FEMALE. WAS THERE A 24 AUTOPSY
<br />PREGNANCY IN THE PAST 3 A10NTHS+
<br />IAgn 10.5.1 Yet I/b Yes Nv
<br />2S6. DATE OF MLIURY (Ma, pay yr•J I 25c HOUR OF fUURY 126& DFSCRIBE HOW NIAIIRV OCCURRED
<br />� 1ae..al brallw 1� Aad xAln
<br />IIIinow bMlfell plael and (ISM
<br />I
<br />I
<br />1
<br />a1 belwm arI Am omm
<br />i
<br />i
<br />25. WAS CASE I EEI To ME=ft
<br />MUkAMNER ^ OR CORONER?
<br />V0i 1 1 NO 12
<br />_ M
<br />(�.
<br />Wm- W011 tRCWY 269. LCX:ATKTN STREET OR R.F D. ND CITY OR TOWN STATE
<br />27D TE SIGNED 1W. Day Yr) 210 ,rm of DEATH
<br />ow bm � �qr.
<br />L27d u°1 .I IirdA k !L 604P unddtow MI D, 1*. 1/d 01- --m 6eIn ow
<br />DSACCO USE CONTFO UTE TO THE DEATH7 - 30a HAS C
<br />❑ YES ❑ No is UNKNOMMI
<br />AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR CM
<br />W. J. Lawton M. D. 2444
<br />'I32a
<br />ter:: 1
<br />_!
<br />y 25� PRONOUNCCED DEAD rAb DA,: Yr I 7fd PROM XoWZt- DEAD NOW
<br />qK�
<br />M S¢
<br />2M !k ON bAAN N e1MNINp+ r duu tl or n..npNUn n.IIT aPwsn nlrh alrwnlo M
<br />*ft. d1r 1m a 4 0 WWI q we ram sO1id.
<br />:�L.•_. W YyM
<br />TISSUE DONATION BEEN CONSIDERED, r30.b WAS CONSENT GRANTED1
<br />❑ YES m NO ❑ YES NO
<br />RNEY) !Typeapfty
<br />91ey, Grand Island, NE. 68803
<br />.. -- - . ..- .__.rI— DATERLFD8YWm1RA4 R*Lv r wo
<br />South Half of Lot 8, & all of Lots 9 and 10, Block 18, Packer & Barr's Second
<br />Addition to Grand Island, Hall County, Nebraska
<br />N
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