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Re: East Half of the Northeast Quarter (E' /2 NE' /) and the Northeast Quarter of the <br />Southeast Quarter (NE'/ SE' /4) of Section Two (2), Township Nine (9), North, <br />Range Nine (9), West of the 6th P.M., Hall County, Nebraska. <br />WHEN THIS COPY CANNES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTE14 R CERTFES TIE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAPWTlC&WTION, WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />OCT _ ANLEY �z£OOPER <br />2 <br />LINCOLN, NEBRASKA 2 0 0 919 9 91 HEALTitANUINAMANCE &SYSTEM <br />STATE OF NEBRASKA — DEPARTR*Jff OF HEALTI!_ <br />BUREAU OF VITAL STATISTICS <br />CERTIFICATE OF DEATH 16 - U S b 3 4 <br />I DECEOkNT NAME —___ flRjT y lD,�E �' _ ._.�_ 2 SF■ 3 DATE CIF DEATH l 0161 D„ <br />Berniecc Edith Sullivan _ _ ;Female Jul 7, 1996 <br />t. CITY AMU ^aTATE C` 2tRTH 7MekYYt UJ'A. rsinM.:OUnaYI T3a kiiE LaN S.aWay UNDER 7 YEAR .:UNDER s DAY 6 DATE OF BIRTH rA4,04 DAy 1,,&N <br />firs -_ Sb MUS '� DAYS 15c HOL'PZ syNy <br />Hastings, Nebraska 68 N ` June 24, 1928 <br />rGrand THa PEACE Oi DEATH HOSPITAL kof OTHER 506 --28 -737 6 M <br />® ER omor:m ❑ ny qunre -Care Ceni.er ❑ DOA ❑ OYMI OR LOCATION OF WT �— Sd. INSIDE CITY LIMITS Sa COUNTY OF DEATH <br />Island Yes >m ❑ I Hall <br />(!k RESIC ENGE -STATE qp COt1NTY i 9C CITY. TOWN OR LOCATION q0 STREET AND NUMBER 1McxdVZpG d I �9u INSIDE CRY LIMITS <br />Nebraska I Na7 t I r_Y�„a TAT �,.a s, , „ ! _. M <br />-- <br />10 RACE - Nq. WhiW. Sink cm awlan. I1.ANi;ESrwleq MaFen. Mgtu1•an. German, +ACi 12. ®MARRIED ❑WIDOWED 13 NAME Of SPOUSE lM lltk Viv emm* nwm) <br />a1C.l ISPaaM White I� *I Q`° NEVER <br />American DIVORCED Roger Sullivan <br />rfvft Wavislp BIM~A'eetddf AYwdllYd abnedlrrg maa 14e KIND OF BUSINESS INDUSTRY 15 EDUCATION ISpecoy ore, Iaghey cone~ <br />Teacher � I EkltM-aary&S*CWdVV 10.121 <br />��' Education - 2 Yea IS ps., <br />FATHER -NAME PiST MIDDLE LAST 17 MOTHER FIRST AYDDLE MAIDEN SURNAME <br />Fred NMI Nissen (Dec.) Edith M141 Watson (Dec.) <br />WAS D{ EVER IW U.SARMED FOFICES9 �9a INFORMANT -NAME <br />. ro a unki 1 iR,es. 9" r ow otles of wrvkal <br />No ! -- - --- -- Roger Sullivan <br />6" NY MAILING ADORES.- ISTREET OR RF D NO, CITY OR TOWN. STATE. gPJ <br />10170 S. Shady Bend Rd., Doniphan, Nebraska 68832 <br />• SMaNATURE 8 LICENSE NO '21a METHOD OF DISPOSITION _m,. DATE 21C CEMETERY OR CREMATORY NAME <br />C�e,w ❑R ... July 10, 1996 Cedar View Cemetery <br />Za 21d CEMETERY OR CREMATORY LOCAifON -ITV OR TOWN STATE <br />Kleine Funeral Home Qr"°" Y0" 00""°n Doniphan, Nebraska <br />�. FUMBAL ADDRESS (STREET OR AF D HO.. CITY OR TOWN. STATE. NPI <br />3213 W. North Front St., Grand Island, Nebraska 68803 <br />TE CM.ISE (ENTER ONLY ONE CAUSE PER _— FOR IaL IDL AND 1.11 f WAMW bs ftvm wwo a,w duo <br />tr <br />OUE 10. OR AS A CONSEOUEN(,c OF <br />�••� i kuer,af bemeen wee -d'ran <br />r <br />DUET0.0RASACONSE-QuENCEOF f <br />Naval baaasal Oral and d"M <br />!CI i <br />ji PART OTHER C!(iNiFICANT CONDiTItkJS - COn7:Dpnt otM rtg m F* 00M W nal re4md P I9 IF FEMALE. WAS THERE A At1TOPSY i WAS CASE REFERfEC TO MEDICAL <br />f1 a PRE Y IN THE PAST 3 MONTHS'' EXAMINER OR CORC4ERI <br />IA9as 10-SAI Yes NP Yes NO S Yee 17 ft <br />1 2811 DATE [IF IN.e i1W I •ie. .✓,..n..e <br />ElAC7dw L--J� Utldewr.wred <br />1 C. S .. l j Pennhng 2o'e INJURY AY WORK 2sI pLAI <br />IWletrea VrveKugoon Yes ❑ NO ❑ Mlce <br />) a. GATE OF DEATH mo Day Y,I <br />s 7-7-9,6 <br />_ <br />DATE. SIGNED (W_ Oay Y.I i • TIME OF ! <br />T4 the osatd 1^Y kl—kl*'A2. IK' -wC1 OCCU1'gd?l q! ARM. data ao <br />CaUa6fe) agMd. <br />fSu,la§,e atleTMi i �!`% t /- <br />❑ YES [a-Np a UNKNOWN <br />r—, faro, Sir" tw" 1 289 LOCATION _ STREET OR R.F.C. NO. CITY OR TOWN <br />eoa <br />­t e D !Aa Day W1 2011 TIME OF DEATH <br />t <br />1 <br />25C PRONOUNCED DEAD (Mo DAy. Yrl 2Id. PRONOUNCED DW 04ow) <br />M S <br />.`- •� 20e On Ale bloc of oxamM aaen aM or fN /eY9aae1. k1 ITN cpnm Ile occur"d of <br />_ ► the W-. deg and Waee and dM b OW CalW atala0. <br />y lSgnYae and Tails] <br />RSSUE DONATION BEEN CONSIDERED WAS CONSENT GRANTED' <br />❑ YES - D-a I ❑ YES �- <br />c>U' <br />o <br />C> -+ <br />N r'4" <br />m <br />tr <br />SL .. <br />=a <br />° �. <br />I� <br />H <br />o <br />< <br />C <br />S <br />O <br />S' <br />Z <br />X <br />c� <br />rV <br />I=> <br />Z <br />y <br />V <br />C-1 <br />t� <br />K3 <br />► _' <br />1 <br />M <br />C.J <br />p <br />' <br />` <br />y <br />, <br />CCn <br />N <br />C C) <br />1.4 <br />V <br />O <br />D' <br />'Ile <br />D7 <br />~ <br />vC!) <br />CD CD <br />M' <br />01C <br />► a <br />rte" <br />N <br />i <br />O <br />Re: East Half of the Northeast Quarter (E' /2 NE' /) and the Northeast Quarter of the <br />Southeast Quarter (NE'/ SE' /4) of Section Two (2), Township Nine (9), North, <br />Range Nine (9), West of the 6th P.M., Hall County, Nebraska. <br />WHEN THIS COPY CANNES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTE14 R CERTFES TIE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAPWTlC&WTION, WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />OCT _ ANLEY �z£OOPER <br />2 <br />LINCOLN, NEBRASKA 2 0 0 919 9 91 HEALTitANUINAMANCE &SYSTEM <br />STATE OF NEBRASKA — DEPARTR*Jff OF HEALTI!_ <br />BUREAU OF VITAL STATISTICS <br />CERTIFICATE OF DEATH 16 - U S b 3 4 <br />I DECEOkNT NAME —___ flRjT y lD,�E �' _ ._.�_ 2 SF■ 3 DATE CIF DEATH l 0161 D„ <br />Berniecc Edith Sullivan _ _ ;Female Jul 7, 1996 <br />t. CITY AMU ^aTATE C` 2tRTH 7MekYYt UJ'A. rsinM.:OUnaYI T3a kiiE LaN S.aWay UNDER 7 YEAR .:UNDER s DAY 6 DATE OF BIRTH rA4,04 DAy 1,,&N <br />firs -_ Sb MUS '� DAYS 15c HOL'PZ syNy <br />Hastings, Nebraska 68 N ` June 24, 1928 <br />rGrand THa PEACE Oi DEATH HOSPITAL kof OTHER 506 --28 -737 6 M <br />® ER omor:m ❑ ny qunre -Care Ceni.er ❑ DOA ❑ OYMI OR LOCATION OF WT �— Sd. INSIDE CITY LIMITS Sa COUNTY OF DEATH <br />Island Yes >m ❑ I Hall <br />(!k RESIC ENGE -STATE qp COt1NTY i 9C CITY. TOWN OR LOCATION q0 STREET AND NUMBER 1McxdVZpG d I �9u INSIDE CRY LIMITS <br />Nebraska I Na7 t I r_Y�„a TAT �,.a s, , „ ! _. M <br />-- <br />10 RACE - Nq. WhiW. Sink cm awlan. I1.ANi;ESrwleq MaFen. Mgtu1•an. German, +ACi 12. ®MARRIED ❑WIDOWED 13 NAME Of SPOUSE lM lltk Viv emm* nwm) <br />a1C.l ISPaaM White I� *I Q`° NEVER <br />American DIVORCED Roger Sullivan <br />rfvft Wavislp BIM~A'eetddf AYwdllYd abnedlrrg maa 14e KIND OF BUSINESS INDUSTRY 15 EDUCATION ISpecoy ore, Iaghey cone~ <br />Teacher � I EkltM-aary&S*CWdVV 10.121 <br />��' Education - 2 Yea IS ps., <br />FATHER -NAME PiST MIDDLE LAST 17 MOTHER FIRST AYDDLE MAIDEN SURNAME <br />Fred NMI Nissen (Dec.) Edith M141 Watson (Dec.) <br />WAS D{ EVER IW U.SARMED FOFICES9 �9a INFORMANT -NAME <br />. ro a unki 1 iR,es. 9" r ow otles of wrvkal <br />No ! -- - --- -- Roger Sullivan <br />6" NY MAILING ADORES.- ISTREET OR RF D NO, CITY OR TOWN. STATE. gPJ <br />10170 S. Shady Bend Rd., Doniphan, Nebraska 68832 <br />• SMaNATURE 8 LICENSE NO '21a METHOD OF DISPOSITION _m,. DATE 21C CEMETERY OR CREMATORY NAME <br />C�e,w ❑R ... July 10, 1996 Cedar View Cemetery <br />Za 21d CEMETERY OR CREMATORY LOCAifON -ITV OR TOWN STATE <br />Kleine Funeral Home Qr"°" Y0" 00""°n Doniphan, Nebraska <br />�. FUMBAL ADDRESS (STREET OR AF D HO.. CITY OR TOWN. STATE. NPI <br />3213 W. North Front St., Grand Island, Nebraska 68803 <br />TE CM.ISE (ENTER ONLY ONE CAUSE PER _— FOR IaL IDL AND 1.11 f WAMW bs ftvm wwo a,w duo <br />tr <br />OUE 10. OR AS A CONSEOUEN(,c OF <br />�••� i kuer,af bemeen wee -d'ran <br />r <br />DUET0.0RASACONSE-QuENCEOF f <br />Naval baaasal Oral and d"M <br />!CI i <br />ji PART OTHER C!(iNiFICANT CONDiTItkJS - COn7:Dpnt otM rtg m F* 00M W nal re4md P I9 IF FEMALE. WAS THERE A At1TOPSY i WAS CASE REFERfEC TO MEDICAL <br />f1 a PRE Y IN THE PAST 3 MONTHS'' EXAMINER OR CORC4ERI <br />IA9as 10-SAI Yes NP Yes NO S Yee 17 ft <br />1 2811 DATE [IF IN.e i1W I •ie. .✓,..n..e <br />ElAC7dw L--J� Utldewr.wred <br />1 C. S .. l j Pennhng 2o'e INJURY AY WORK 2sI pLAI <br />IWletrea VrveKugoon Yes ❑ NO ❑ Mlce <br />) a. GATE OF DEATH mo Day Y,I <br />s 7-7-9,6 <br />_ <br />DATE. SIGNED (W_ Oay Y.I i • TIME OF ! <br />T4 the osatd 1^Y kl—kl*'A2. IK' -wC1 OCCU1'gd?l q! ARM. data ao <br />CaUa6fe) agMd. <br />fSu,la§,e atleTMi i �!`% t /- <br />❑ YES [a-Np a UNKNOWN <br />r—, faro, Sir" tw" 1 289 LOCATION _ STREET OR R.F.C. NO. CITY OR TOWN <br />eoa <br />­t e D !Aa Day W1 2011 TIME OF DEATH <br />t <br />1 <br />25C PRONOUNCED DEAD (Mo DAy. Yrl 2Id. PRONOUNCED DW 04ow) <br />M S <br />.`- •� 20e On Ale bloc of oxamM aaen aM or fN /eY9aae1. k1 ITN cpnm Ile occur"d of <br />_ ► the W-. deg and Waee and dM b OW CalW atala0. <br />y lSgnYae and Tails] <br />RSSUE DONATION BEEN CONSIDERED WAS CONSENT GRANTED' <br />❑ YES - D-a I ❑ YES �- <br />