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C R <br />t Z U <br />U DAIS OF '.1 We Yatl <br />M <br />G <br />n n <br />m y <br />August 25, 2003 <br />r axO SrAreoF awiH 11-11x . namowwwv, - A <br />AGE la„EAYAW - <br />UNwI YEAR D <br />DmrDnv e <br />e. - <br />mMDS. IvDAVS s <br />s wuPS M J <br />January 28, 1922 <br />Elm Creek, Nebraska _ <br />c° <br />o-H <br />—IX . wULCVmnNUMDEP P <br />P'w HOSPITAL ?H ❑ In abT ❑ N sr9 a <br />4c41 -16 -7062 — <br />— -- m <br />SE -N.- WAY- wwno,,. w+ �e,ww AV*e..i ❑ <br />Francis Skilled Case ❑ <br />❑ DDA ❑X DmNlScervw SkiT�_ <br />,rvm LOCnnory aF OFnnr — <br />OTYGMIrs c <br />couxry DF DEArH <br />Grand Island e <br />a �] MA ❑ H <br />Hall <br />4 cn TOWN DR ox N AdxNra '- smecry LMTs A <br />FIC S <br />Nebraska Hall Grand I <br />o I::P., I . -Lms INPAP. Menw.n OMmm ew D � - <br />.wl we =a1 White F <br />FD cATDe SG.MMwvnonwLOwaN*+1 <br />SENAMANnN.1 Y <br />Gx ir.,:;rww.wm»wwm ma wxwFMUgxFSSlNwsiAr F <br />w.HWAINM --- <br />Regional Director Insurance _.._ 12 -- <br />6 FAIHLH. NAMF Fw3i - AlDDLE usl �. MOmEA Flasl MIDDLE -' uuUEx s„DxAME <br />James Thomas Fox Paarl _ Teller <br />AE DECFASEO IVFI N IS m PLES? IHFIXIMANL NAM[ <br />IDn ° <br />°.. An nr •L1 » =e+. wYMEDa Marion L. o <br />xese 1- 4 <br />wIODMANT MMLINDAO p I,FP OPF.FD. x,. - OPTDwx. STATE. SIGN <br />2417 Apache Road, Grand Island, Nebraska 68801 x <br />x cEMFrEPV OP <br />EU MEPS r ncF NO 'A MEMCODEtlsPOPnux Im GATE c WENATOPV NAME <br />m'� L <br />AllwFaiths Funeral Home ❑L,,,,,MwA❑ -AA- Grand Island° Nebraska <br />RE. FUNERAL HOMLAVUPF65 IETPEET OP R FD. DO QI H VP TYPED SiREEIFI <br />2929 S. Locust St_, Grand Island, Nebraska 68801. _ <br />IMMEDIATE CAU�9E IEx rtH LIN Y ONE CAUSE PER LNE FOR 11 l01. AND 191 n IPInrN Wwavnmaw,neeexn <br />` <br />PM1 I <br />INe —1 A m <br />- UUL IV, OP ASAf.ORILOL CEOF <br />IN _ NMnA ueveeA mer eTa umm <br />DIE TO IRALWGI.-O-I .1 <br />I[I - pppi IN lF fEMAIE.WAS iNEPEA N MTTOPSY A6CNEE REFERRED TO M[ IT <br />EP SIGM— I hp101TVxx- Cwlmnw emulWUnpw rAJeaN ddnel�eMrm EGNM,CV IN THE PSy,JMOxiHS? exnMl OE CORONERI <br />PAPr II uPF s.I <br />AN, 1 <br />11 DATE n"IVPV 1 11 11 A <br />Aw OUR.... % <br />t E nOw IN.I T <br />a <br />T• <br />❑ <br />8.. W <br />r lumy t <br />TY <br />�% <br />T <br />W U <br />rn <br />e <br />❑ NA ❑ _ <br />_ <br />DAILOEOFATM AND DAY vy ' <br />'tl,. DATE SIGNED Mw.Dµ r, L <br />A, „ o <br />a P <br />- D <br />L��T" <br />S,- A <br />of 2 <br />TINEOF a <br />- <br />D M <br />g21 D <br />:L n <br />8, A- LA 6 <br />6zE A <br />M <br />APmnA M <br />nC%3. 8 <br />N <br />x <br />O E3 <br />LON9DEPEDi wes v0 MNiED? <br />❑ IRS Z NO ❑ H <br />`xV ❑ vE4 1� NO <br />NAMFANDA- 1111DFCEI lle IA -GLAD WPO xEPS PHYSICIAN OR COUNTY AFTORAFY ,Mwo Pmrll <br />Gordon _Hrn icek M.D. 72 N - ti d <br />J <br />d <br />N <br />0 <br />Recorder: Lot 10 in Block 4 in the Replat of Riverside Acres, an <br />Addition to the City of Grand Island, Hall County, Nebraska <br />c <br />WHEN THIS COPYCARRIES THE RAISED SEAL OF THE NEBF <br />SYSTEM RCERTIFWS THE BELOW TO SEA TRUE COPY OF <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE DF ISSUANCE 200314088 M 6:A� R <br />9/17/2003 ASSISTANT 1141TRAR <br />LINCOLN, NEBRASKA _ HEALTHAND NUMAN SERVWS SYSTEM <br />STR M OF NEBR M.DEPARTMENT OF HF.11.TH AND FNMAN SERVICES PRDMcEAIR1SOPPoRT <br />VITAL STATISTICS _ -_ 03 10303 <br />IDHILLLNT nMF FIRST MIDDLE IPIT t <br />t Z U <br />U DAIS OF '.1 We Yatl <br />Charley Wayne Fox M <br />Male A <br />August 25, 2003 <br />r axO SrAreoF awiH 11-11x . namowwwv, - A <br />AGE la„EAYAW - <br />UNwI YEAR D <br />DmrDnv e <br />e. - <br />mMDS. IvDAVS s <br />s wuPS M J <br />January 28, 1922 <br />Elm Creek, Nebraska _ <br />el m <br />—IX . wULCVmnNUMDEP P <br />P'w HOSPITAL ?H ❑ In abT ❑ N sr9 a <br />4c41 -16 -7062 — <br />— -- m <br />SE -N.- WAY- wwno,,. w+ �e,ww AV*e..i ❑ <br />Francis Skilled Case ❑ <br />❑ DDA ❑X DmNlScervw SkiT�_ <br />,rvm LOCnnory aF OFnnr — <br />OTYGMIrs c <br />couxry DF DEArH <br />Grand Island e <br />a �] MA ❑ H <br />Hall <br />4 cn TOWN DR ox N AdxNra '- smecry LMTs A <br />FIC S <br />Nebraska Hall Grand I <br />o I::P., I . -Lms INPAP. Menw.n OMmm ew D � - <br />.wl we =a1 White F <br />FD cATDe SG.MMwvnonwLOwaN*+1 <br />SENAMANnN.1 Y <br />Gx ir.,:;rww.wm»wwm ma wxwFMUgxFSSlNwsiAr F <br />w.HWAINM --- <br />Regional Director Insurance _.._ 12 -- <br />6 FAIHLH. NAMF Fw3i - AlDDLE usl �. MOmEA Flasl MIDDLE -' uuUEx s„DxAME <br />James Thomas Fox Paarl _ Teller <br />AE DECFASEO IVFI N IS m PLES? IHFIXIMANL NAM[ <br />IDn ° <br />°.. An nr •L1 » =e+. wYMEDa Marion L. o <br />xese 1- 4 <br />wIODMANT MMLINDAO p I,FP OPF.FD. x,. - OPTDwx. STATE. SIGN <br />2417 Apache Road, Grand Island, Nebraska 68801 x <br />x cEMFrEPV OP <br />EU MEPS r ncF NO 'A MEMCODEtlsPOPnux Im GATE c WENATOPV NAME <br />m'� L <br />AllwFaiths Funeral Home ❑L,,,,,MwA❑ -AA- Grand Island° Nebraska <br />RE. FUNERAL HOMLAVUPF65 IETPEET OP R FD. DO QI H VP TYPED SiREEIFI <br />2929 S. Locust St_, Grand Island, Nebraska 68801. _ <br />IMMEDIATE CAU�9E IEx rtH LIN Y ONE CAUSE PER LNE FOR 11 l01. AND 191 n IPInrN Wwavnmaw,neeexn <br />` <br />PM1 I <br />INe —1 A m <br />- UUL IV, OP ASAf.ORILOL CEOF <br />IN _ NMnA ueveeA mer eTa umm <br />DIE TO IRALWGI.-O-I .1 <br />I[I - pppi IN lF fEMAIE.WAS iNEPEA N MTTOPSY A6CNEE REFERRED TO M[ IT <br />EP SIGM— I hp101TVxx- Cwlmnw emulWUnpw rAJeaN ddnel�eMrm EGNM,CV IN THE PSy,JMOxiHS? exnMl OE CORONERI <br />PAPr II uPF s.I <br />AN, 1 <br />11 DATE n"IVPV 1 11 11 A <br />Aw OUR.... % <br />t E nOw IN.I T <br />a <br />❑ <br />8.. W <br />r lumy t <br />TY <br />a- ❑ <br />W U <br />e <br />❑ NA ❑ _ <br />_ <br />DAILOEOFATM AND DAY vy ' <br />'tl,. DATE SIGNED Mw.Dµ r, L <br />A, „ o <br />a P <br />- D <br />L��T" <br />S,- A <br />of 2 <br />TINEOF a <br />- <br />D M <br />g21 D <br />:L n <br />8, A- LA 6 <br />6zE A <br />M <br />APmnA M <br />nC%3. 8 <br />.v°ggfla <br />4d T <br />THAT N m <br />uEEM L <br />LON9DEPEDi wes v0 MNiED? <br />❑ IRS Z NO ❑ H <br />`xV ❑ vE4 1� NO <br />NAMFANDA- 1111DFCEI lle IA -GLAD WPO xEPS PHYSICIAN OR COUNTY AFTORAFY ,Mwo Pmrll <br />Gordon _Hrn icek M.D. 72 N - ti d <br />J <br />