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 �-
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<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 />
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