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<br />ERtered ~ tnstroment No
<br />o 2 0 0 603 282
<br />
<br />STATE OF rEGR.ASKt\)
<br />COUNTY OF f-l.ALL ) 55
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<br />Port II
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<br />
<br />Census T roc! No.
<br />
<br />BV5- 2 020-M.006 12-32
<br />
<br />
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />
<br />
<br />DECEDENI NAME
<br />
<br />MIDOlE
<br />
<br />LAST
<br />
<br />OATE Of OEArM (Mo.. 0..,._ Y..)
<br />
<br />fiRST
<br />
<br />Otto
<br />
<br />Marius
<br />
<br />Albertson
<br />
<br />1986
<br />
<br />1
<br />RAC E (..9.. W,,~. Ilac\. A....;can OlI!GIN/DfSCENT (. .9.. 1."I;an, Me.;can. AGE -La! ..rto.d.....
<br />I n<lian, ole.) (Sp~;1-, 1 (Y ro.)
<br />~. White j.
<br />CITY AND STATE Of BIRTH (If _I in U.S......
<br />Mime C'ClP1lfrJ'J
<br />
<br />1908
<br />
<br />8.
<br />SOC IAL SEC lJIlTY N UMla
<br />
<br />\3b Food/Bakery \40.
<br />HOSPITAl OR OTHER INSTITUTION - Name (If no' in ei,~."
<br />
<br />Hall
<br />
<br />If HaSP. 01 I""'Sf. I n:dicote- 00.....
<br />Ov-tpa I i..,t/E_r. I:JI!I., Il'l.l=Il;Iri.1'I1 (SPoil(" ilr)
<br />
<br />Ub. Alda 79 Rt. III '....e. NA
<br />RESIDE NCE -STATE COUNTY STRE ET ANO NUMIER ,INSIOE CITY LIMITS
<br />lj.,Nebraska Hall AIda 79 I (Sp."fy Y.. o. No)
<br />Hb. IS.. No
<br />FA THO N.IuItlE FIRST MIDOLE lJIST MI DOLE LAST
<br />
<br />16. Unknown
<br />
<br />W AS DECEASED EVER IN U. S. A lME D FOliC ES?
<br />[l' i!'~, 1'10, Oil' i,II",.l! {K p1I. -g r...... WCI r ond da l'!lt ~f ~..-vi-(:C'}
<br />
<br />18. No --------
<br />
<br />8 U III AL. C...ma.;",.. Rem""", I 0.1. TE
<br />
<br />Albertson 17 Unknown
<br />I INfORMANT - NAME - REtA TIONSHIP - MAILING AOORESS [STUET OR HD. ..0.. cm 01: TOW"', Su.n. ZIP)
<br />
<br />19.Marcia Albertson(Wife)Rt. III Box 79. AIda, Ne. 68810
<br />CEMETERY OR CREMATORY NAME lOCATION CITY OR TOWN STAff
<br />
<br />27,1986 2~Westlawn Memorial Park 2~.Grand Island. Nebraska
<br />fUNERAL HOME NAME hND ADDRESS (SnUT 01 H.D. "'0.. CtTY 01 TOW"'. STATE. Z1f1 68801
<br />
<br />nLivingston-Sondermann 505 West Koenig, Grand Island. Ne
<br />z',.. VAlE SIGNED (Mo. Day. Y..) I HOUR Of DEATH
<br />~ . ~0i I /tf-(-g'"6 V
<br />"tI=U ",30. "V-a 1"'0. /"
<br />i~ ~ DATE SIGNED- (Mo.. Day, y,) HOUR Of DEATH j~~ . PRONOUNCED DEAD
<br />t";J I I ::~fl\Mo.. Day. Yr.)
<br />~~ l23b 23< M j:50 24<: 9 24 86
<br />.:~ I To tM It.. of., .~edg.. cl!eotl\ -CI<l::urr.cf at 'M filM', do'" ond p~cu:. ond du. Ie- th. j' 5 0 eM -+-. bout. of- uGlIIIlnal10n o,"d/or in
<br />~ ~ (Qug(.J) &foteG :! 8 ~ I'. 1i...., dGt. end pl eM:. and d.... tel
<br />, 23d (Sig"a1wre .oM Tine; ..... 1,(e. (Sj glllahl'f"e and r in.} ....
<br />V NAME ANll....DOIIESS Of CERTifIER (PHYSICIAN. CORONE R'S PHYSICIAN 011 COUNTY _nORNEY) (Type o. Prinf)
<br />
<br />25. Jon Rath, Deputy Hall County Sheriff - //7 ~'. /4- drconff:::.k7nc{, ;1).e.--,
<br />
<br />I REGISTRAR IOATE RECEIVEO BY RfGISfRAII (Moo., Doy. y,.)
<br />
<br />~ 26a.iS.."......I~ ,26b.
<br />27, IMMElllATE CAUSE (ENTER ONlY ONE CAUSE PER LINE fOR (01. (b), AND (e))
<br />}' PART
<br />:01 coronary occlusion
<br />OUE TO, 01: AS A CONSEQUENCE Of,
<br />
<br />:# ;:J.,s- i/ "
<br />
<br />Ub. B : 15 a .
<br />liONOUNCED DE....D (Hou. J
<br />
<br />2~d. 10:14 a.
<br />ion~ ift .., opin iGn death
<br />u1oe(.l stohtd.
<br />d<
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<br />M
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<br />'"'~ I betwe-Ho GrIIlfl o-ncl deoth
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<br />In"'r"'Ot b.....ei'I 0r'I-tIe-t an d a.-c:l""
<br />
<br />,bl
<br />OUE TO. 01: AS A CONSEQUENCE Of,
<br />
<br />!1I.,.tval b...........- Ocr,...' and d..-a It!-
<br />
<br />(<]
<br />P AIll OH'P SK>NIf1CN<T CO+<OITION S
<br />II
<br />
<br />ConditioM cOI"IlTi b~ti"'g to d.-o-t+s bv' 1'101 r.lot4d ( P AIT ~;I. If FEMAt E, Vi AS- THflE ..... lI. UTO'S Y
<br />I '.ECto.'ANC..,IN THE PAST J MONTHS? {S".ci'r Y... Ot" No}
<br />
<br />Y.. 0 ~lo C' 28. no
<br />1t0UR OF 'ttjun ~a.n o;ow ,...,un OCCU.IEO
<br />
<br />3Oc. M j 30..1.
<br />LCeAno..
<br />
<br />WAS CAU REf enE D TO ME llICAl
<br />EUMlNER OR CORONER
<br />ISp.d, ~~~oJ
<br />29.
<br />
<br />3lle.
<br />
<br />
<br />JOg,
<br />
<br />ACCIDENT, SUICIDE. ItOMlCloe. U...Off .
<br />OR ,e"'DlIfGIN""ST>G.\TtOtt.IS_'''J
<br />
<br />)0."
<br />IttjUIY AT WORIL
<br />(S_if,- y.... IOoJ
<br />
<br />DAlE Of INJUI"I' lMo., Do,~ '(,-.J
<br />
<br />C'TY 01 TOWN STAn
<br />
<br />sneff 01: U.D. .....
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