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STATE OF NEBRASKA <br />WHEN THIS COPY CARRIES 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 STATISTICS, SEC7101%;WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE N' <br />MNLAW S COOPER <br />MAR 0 1 2006 200602 0 g g ASSYST4NT gif - REGISTRAR <br />LINCOLN, NEBRASKA 4AL_ _ A1W j4UMAN SERVICES <br />STATE Cr)Mg&Awf& DEMRTio f CV ERA1,TR AM lI MAN SRVKU FWAHM AM i{J!!'M <br />VITAL 3TAtff= <br />CMUTFIc.AIMOF DEATH 99 05978 �. <br />a 7malv 10. 1 <br />.rdti#..1ra Lrlt i , Y riyrf <br />�G A nw� aar"W <br />M»Ni March 9 1928 . <br />6�isseart Nebraska 71 , <br />rM , <br />' MO�1'AL � nArlar O,�r ❑ Nwlq HeaSa ; <br />506 -22 --8212 ❑ IE"�wl ❑ A"a"M i <br />•,waa iraoriullROna�+rrrandnlwlMwl - <br />St. Francis medical Center Q �A ❑ a�.- /ate <br />�n n �c M1 Hall <br />A � GON <br />AND A�!0 M. ' <br />Nebraska Hall Alda, 41 Venus 68810 VF "°❑ <br />,0 •eoi, WlMl tact Aldil[Yf YIdiW!. 1;. tRYNy- odMA. M,a�tiA olCl ,2 1S NAME Oi BPDUSE (P IMw PwAWdM�AIipw <br />aae,dAewty art « owalant,o Joan L. (Ndw1u,n.) <br />,.. UeUAL00M^TKW i w.AhdM.'Cf+*Wcutvmoo ,u, BUA21E3S>r UbTRY ts. WMATIDN <br />A /MITI open*" W&TA( Ydf Me0r111ryM•1F21 CCMOd Y1Ji1fY1 <br />Supervisor Monument Com any T �f <br />14 FA .NAME -wl- MI t.E LAST t7 MOTHER :iR6T mom WIDEN . <br />Edward Sebesta Sr. _ Bessie Oliva <br />Wk WAS ER ad U nRMEnr"''ESV Sol. awrtlIIMANT • NAI/E <br />Jean <br />rvaa nA. eY Ue�.I i:rva.4"w.xir alp duw �r aaerlrraal <br />H6^ - AWI.1Mfl AnDREEd W ISTREET RG.D HO.. CI'M 4R TOWN. iATLS. ZIP1 .•••�"'^ _. -. <br />41 Venus Alda, NE. 68810 <br />20 EMBALMO -BONA Al."C4NS..W ,aMTtwOO ITIWr 2,a DATE �e' CIEMErERYDRCRELIWTORY NAME <br />Not Embalmed ❑ ❑ Mal+ 10, 1999 antral Nebraska <br />no f:L*; MAL HDME • K&A* ra CFAPETERY OR CREMATORY L aTA <br />Kleine Funeral. Home ate°" ❑°" Gibbon Nebraska <br />226 FUOIEpAI. ADDRESS 19T T OR RF.D KO.. CITY OR .STATE. MM1 <br />3213 W. North Front <br />S Gra 1 N& 68803 <br />PpART%SX=TeCAUSfi {ENTER OtaLY ONE CADS[ PER t.D1E . ft AND (CI <br />•�,Y� T�+ � <br />1 lal �i'ir SIS aaFYM 6a1wMl daaM 011d dallR' <br />DUE TO.OR AS A COT18�YXIEraGE OF 1 <br />ro( f'ANCER Off' COLA18 � ►'t�nw6rl...nuelalr,dd.r� <br />WF TO- OR AS A CONSFSuENCE OF: <br />1 <br />PART�R WiNIFICANT CONDITIONS • CM,OOdnA c74�WYgAOIne duro but nd rl'artl PAW M WCY 04 THE PAST 8 MONTN$T " ".era. CC11gVE <br />a (Ag w *p K Yaf.' F1 to I Yes t10 Vaa 1b <br />2� .'M6. DATE OF (NlURv Mkx. DPY. Yrl Ilk HDUR OF IHA SY 2!d nESC"OE HOW WAIRY W-LIRAED <br />© A.O t ❑ UMO. -nnad M <br />❑ $,q,pl '❑ pinp,ny 26a. NIJURY A7 WOW: <br />=& WRY CRY - t1 . W+*.:Se W WAVY 24 L�TIPRY STREET OR R.F.D. NA� GYTY OR TOWN <br />❑ Hc- q W0090. T O ❑ No E 4WD �-- �-•� —� <br />L_ DATE OF DEA7H fW. DaV rill t 2EO OAT£ SK91I6D /M7. GM <br />RL w7 206 TIMi d' OFILTH <br />-MAY 10, 1999 ! s <br />fb DATE to" (Ilia.. D�l'� wi 2�,e TIME OF DlAfH 21c. PROMOUNCEOOEAD Ab -aw rill 21LL PNONOVHCEO DEAD /hb6 <br />MAY 10, .1999 1:00 P M p I <br />1Kd, TV ON 6OR Cl lay anORgdg. ola 61SM, dale And dW b p Rio On MN 6aYa daaanlnYdd aral'v OMIMYbaA6rl, 1a my 4S:Y9n dr16 deeSxrad M <br />caumalawld 6 orvml .tleeardpM"OaMdw4ggeaulNalawd <br />Owat"wdTiftW <br />DIb TOBACCO UBE GONTRRW . TO THE O.J.Tli'� HAS OR T1g51/F DONATION SEE DT n WAS comma ORWEO+ 11 ❑ YE5 NO umon", `' YE5 NO - - -- [] Y ND <br />