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<br />WHEN THIS COPY CAMMS THE RAISED SEAL OF THE NEBRASKA HEALT Etb18dA $ ERVICES
<br />SYSTEM, !f CERTFIES THE BELOW TO BE A TRUE COPY OF THE 0 i E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITA HIS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE h3, C i
<br />APR 3 0 2003 200310310 , ANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH "' EU
<br />STATE OF NEBRASKA — DEPARTMENT OF HEALTH 73 0211?
<br />Bureau of Vital StadatieE
<br />t CERTIFICATE OF DEATH J. 5 5 d sum no NN-Yii
<br />—NAME r1MT -MNNt LAST SEX
<br />DATE OE MAIN I MONTH, DAI, UAt 1
<br />1. 1.
<br />SIMON
<br />1.
<br />RACE wNNS. NNOeo, ANe11CAw Ng1AN, AGE—Lm
<br />IIIIDe1 I rut
<br />I Mr
<br />GATE Of Sum NDNTH, DAY,
<br />COUNTY OF L1EA1N
<br />STC. 1 WO"I NlTWAr IYTAtsI
<br />Nos. DAYS
<br />NODe4
<br />MN,
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<br />_
<br />1. White S
<br />A. I
<br />k.
<br />S• 8
<br />f1. Hall
<br />CITY. LOCH OF DEATH NsIDe cm UNITS
<br />NOSPIIAL OR OTHER ION —N cN Nor IN TITHE*, clue we1eT AND wv'm 1
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<br />SOCIAL SECUMIY NIIAIRER USUAL OCgRATION cows NNO a w, Dow DUNND row OF KM OF BUSINESS OR WIDIRSTRY
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<br />— lAW0 COUNTY CITY, TOWN. OR LOCATION "am Cm um" STREET AND
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<br />—MAIDEN NAME raw wogs IAw
<br />August J Deminski 116.
<br />Margaret Koch
<br />111.
<br />a1EOMUM— NAME— REIATIONSINP
<br />MAING ADDRESS ISMM 011.r.D. NO., Cm DD MIONd, STAN, tut
<br />Mrs. Bertha Deminski - Spouse
<br />1,,,.419 North Waldo, Grand Island, NeD 68801
<br />1• MAIN WAS CAUSED ST: IRMO ONtT ONE CAUSE PEII tW FOR (a), Ib1. MO Icll
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<br />PART 111. M FEMML WAS THEME A
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<br />LOCATION c snen 01 I.F.O. NO., cm oe TOWN. RAN 1
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<br />CIRIIIRCAiION— MONTH SPAT UAe I MONTH am reA1
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<br />DEATH OCCIIMED AT Tw PIACt, ON WIT
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<br />CHMVICATION —M DICAL EXAMINE* OR : ON lw LASa OF ON NOW of D"T" TNe D$CIODNT wA$ VIONOUNCeD 9
<br />eNAMNATION Or 10 MITI A10101 RE TIONSTICATION. IN MY OPTHN„I, AIONrN DAY YEAe IIOW
<br />TRIP OCCOMM ON ON DAN MID OUE TO NO CAUw1f1 STATED.
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<br />Cut Nw —NAME ITT" M N11N11 SKINATM Due as INIe DATE SIONW IrON1N, OAT. ""I
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<br />►1�iE` Ml""a" "NI "�` 820 West Division St.. GGrand Island N27 6001
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<br />IMNOM, *AT. NAZI NERAL NOME —NAME AND ADDRESS I STUM M R.F.D. No., Cm on TOWN, $TAN, RIP I
<br />1M. Feb. . — 6
<br />E SA MI�- SIGNATURE a LICENSE No. l� REOISTRAIt— SIGNATURE
<br />RECORDERS MEMO: "�/n4tJ�' Ctd� "',2--5r / 1,I- /,�/7 4- _T 2- .7I LY /4
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