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<br />0''' <br /> <br />WHEN THIS COpy CARRJES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMAN SERVICES <br />SYSTEM, IT CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOR,?QN FILE WITH <br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA TISTlC~'~CH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ;V;;t;~~'"'-~"h."'~", <br /> <br />DA TE OF ISSUANCE JV'!r~~NLEY ;-'cdQPEi'i <br /> <br />JAN 2 7 ZO06 AsSistiwr'STAfE,REGIStJ8tFi', <br />LINCOLN, NEBRASKA 2 0 0 6 0 2 8 8 ~EAL TH AND~U~N SERVICES $YfTEM <br /> <br />. . <br /> <br />I t. PKIO&lT. ':o..rd <br /> <br />., I;m' <br /> <br />STAlE OF~OIiPA1lDOlNTOF HEAt:tHANDHIAfAN SDVICBI ~__BtJftIOU ,-i~'~' <br />ViTALSTA11STICS . ,"=-" <br />CERTlFICATBOFDEAnJ . 98 <br />2 $V< <br /> <br />--- <br /> <br />u.oc:u <br />Laval <br /> <br />LAST <br /> <br />, -o...~ <br /> <br /> <br /> <br />Male <br /> <br /> <br />10879 <br /> <br />Grud....1Id Nebnsb <br />~ <br /> <br />_t'l'lWl UNr/flIt <br />$0. lIOS. Oo\V8 So. HOUlIlI ' <br />I <br />II. "'-'CE 01' IlIA Tl< <br />~AI.c l:i1....... ~. <br /> <br />OPl~ <br />o !lOA <br /> <br />,- ~ 23.1919 <br /> <br />D""'""'u- <br />D- <br />O oo..,*-< <br /> <br />._ (If",_",,__~ <br />St. f'ruds Medical Center <br /> <br /> <br />,', Ol'Il.OCll <br /> <br />Grud &laRd <br /> <br />... <br /> <br />Nebraska <br /> <br />Ill. <br /> <br />Beverly R. Jlldy <br /> <br />15, EllUCA.TICfI I <br />~"'-"""1O"1Il c..., ........1>-1 <br /> <br />~ ..- <br /> <br />Gertrude <br /> <br />PauUae RollI <br /> <br />2.D, DATE <br /> <br />21C. CWElVIYDl'ICREi.tATOIW . ftMIE <br /> <br />.. <br /> <br />#1011 I!J - 0 _v", <br /> <br />o c-... 0 Conal"", <br />OIl R.F.D. NO.. CITV OR TOWN, $TATlO.;!!P1 <br /> <br />09109/1998 Westlawn Memorial Park Ce.... <br />214 CEMI!ttRYORCIlliW.TORf Tl(lI< C'T\'OATQMI "'Aon; <br />Grand Island, Nebraska <br /> <br />1123 Welt Seeoad (. f Iud Island, Nebraska, 68801-5899 <br />n ~. <br />'"""'" <br />I <br /> <br /> <br />---....- <br /> <br />lICE OF <br /> <br />----- <br /> <br />IIIl <br />~ TO. OR ASA CQN8l'QUCNCi OF <br /> <br />~ tII/MIIItfI..--.a..., <br /> <br />1<. <br />II OTHER SlllNR:ANT CONOITlOIlS. ~ comtu1ngION_Il\Il..._ <br />M1' <br />. <br /> <br /> <br />210 .. ClATE OF INJURY IMo-, DIy. Yr.1 28c HOlIIl OF INJURY <br /> <br />i 0 "'~ 0 u..-....... II <br />I....., 0 - <br />I U - "-'1/ IHo ItIJURYArWOllK 2e' ~~NJ~RY,~,I.'m.."....tocIOoy j2e9 lOCATIO" STIlEETOil Il.FD 140, e.TTOATO".... <br />iO -... "'-.. v..D:QJ I <br /> <br />) ]". DATEOI'DEATH r;\l> Goy Yo; '~DAT~SlGNfD I"'" Clo, Y'/ ':lID _OF~'" <br /> <br />It~ i SeptentJer 5, 1998 ' &!; k <br /> <br />1~~!2'" [;~~~ ~,y" (c ~M;~2DEf;~ lId!.. a -~ ~ ,.,", I-~-- <br /> <br />AI M I; _ I <br />~ 2';::t f~t*1IMticllt~_ ~octilr1fGat e _ O"'tnfbMltd.!tDfl'\i~hQrl""'.OI,"~.,"my~(tHti'JOC:e~.: <br />CII~SI'" .- ~ tftel1n'J1.Q'_ancIpII(;e.r!"'~wt""tht~'I.-cl. <br /> <br />STATE <br /> <br />... <br /> <br />.. <br /> <br /> <br />.1. <br /> <br />;0." WM. CON8I;NT GI!A!;TED' <br />o VEl; <br /> <br />~N(l <br />r <br /> <br />1:!2l> DATE FII,E() 8' IlEGIST~'" .. 0Iy. Yr.1 <br /> <br />.sEP 11 'S98 <br />