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<br />,..~ <br /> <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORI? ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC~qft>>I,Wl}lCH IS <br /> <br />J:A:EN~;2:7A;;..u.O:O:60~TORYFOR WTAL REC~ JYIii!r:ii;~ <br />{. AssisTANT'STA TEJ~E!3IS1JfAR. <br />LINCOLN, NEBRASKA 2 0 0 6 0 2 8 8 &tEAL TH AND'f!UMANSERVlCES ':7If'"! <br />RE~RECORDED ,t ,t 4 <br />200603~~ <br /> <br /> <br />.. <br /> <br />I. <br /> <br />T.HoWE <br /> <br />ST"1Ec..~OIlPA&1MIlN1'c.. HIW.llIANDH1.D.fA)I SEaVICBIJl1NANCaANb~ ,:}' <br /> <br />CERm:~~~EATH . ..'98 10879 <br /> <br />2 IlV< <br /> <br />MSl <br /> <br />MIOOU <br /> <br /> <br />lAST <br /> <br />LeoDa"' <br /> <br />Laval <br /> <br />A. _"",. <br /> <br />~"Ii!iJlllg.t._~ <br /> <br />Grud ..Ia.. Nebnsb <br />....... <br /> <br />... ~ OF OltATK <br />i408JIIfAl.: [jj..... <br />DElI~ <br />D~ <br /> <br />~ <br /> <br />._ fJt...._,.,.__~ <br />Sf. Fnllds Medical eNter <br /> <br />.-..------.-- <br /> <br /> <br />'fM <br /> <br />.. lMrS <br />.....~...o <br /> <br />BeverlyR. J8d, <br />16. IEDI.lCATION <br />"*T"-" 10"21 c...., ......~., <br /> <br />llIOOU! ~_ <br /> <br />Gertrude <br /> <br />PauliDe <br /> <br />Rodt <br /> <br />124 Eat Capital Al'enae, Grand Island, Nebraska 68801 <br />30. .~ 211 llET!tOOOFOISPOSlT'ClN 21b. DATE <br /> <br /> <br />21<. caETlFl'f 011 CN!;';'TQFI't _ <br /> <br />#1011 I!J -- 0-., <br />Dc.-O- <br /> <br />0910911998 <br /> <br />WestlaWft Memorial Park Ce..... <br /> <br />21. CEMETERY OIl CIlEMATOR'r lOC"'rDoI <br />Grand Island, Nebraska <br /> <br />e'.....ORTc:Mf\I <br /> <br />""lE <br /> <br />1123 West Seeoad (., Iud Island, Nebraska, 68801.5899 <br />:n~ ~ - ~ 'ENT!RONl.VONEC"l!SE~IlUN/;FOA'.I.I~.<lNOI<1I <br />,~ ~~ r1~.rr ~i~~ <br />Cli(; 011..," ~Of <br /> <br />~ <br />CUI; TO. 011 AS" COOISIiOUE~ OF <br /> <br />---....- <br /> <br />----- <br /> <br />~~_......, <br /> <br />1<1 <br />"AIOT tIllER SlllIoIFlCANT CONOlTIOHS - c..a.;o." c--.g to ,.. _ ""'..._ <br />. <br /> <br /> <br />J5 WAS c.uE IlEJ'liIIIIED TO IiiiiiCil <br />E__OII~. <br />.... <br /> <br />P<lIlT III IF FEM<llJ;. W"S THEFIf .. <br />I'RfGN!\NCV IN ltfE ....ST 3 t.1ONTH$' <br />I. 'O.SOI Vn 010 V.. <br />210 ., ().<\YE OF INJURY IMD. Day. '(<I l!6c HOIJIl Of INJURV I :!ed. DESCRl8lO HOW INJUIlV ace. UAAl'iD <br />10-'<.<-0""- M.. <br />I 0 - 0 "-"<I I ~ INJUIlV "T \IIORI( 28' ~&.~""M~Y ibi3f' I..m. ._.looIoIy 1259 LOC"TION STiOEET OR Il.F 0 /ro. <br />: 0 _<II "'-"'" _ ,110...0 I <br />~ -lv, o.al~OFDEATH ,.., eM, Y'; ~ O"T~9lClNlOD (MtJ f)O,.Y'1 l_llMEOFliEAT>< <br /> <br />~~ i Septeaber 5, 1998 ' $U l, <br />Iff' ~ P;,;-,,-.;:r-~Mc 00, y" i 21< ;~;2DE1;~ M II h l!6c PPO~out;CEDDEAD (MtJ o.y'(<, ! aiel l'AOI\lOU+lCEDDEAD ~, <br /> <br /> <br />~ 2';1 t('1t"11t1f11:CJI'I'l'l1i11 ~oe..'"vr1fdat :Jga 2&t Ontnl.buia"Jhll"Otl'lil"!aDonIlt1d'arln~,,,,,,",~_.,,\X'C:Yi'tId.1 <br />CIIut1lS) -..od .- '.: ! the tlM.."Ite.I\d.,.M \,lilt to hi caw.lBI.-d <br />~ '; ~-.. Sa AiI'l',ancsfltN <br />TE OTHEOO"T'" ,'1 300 ....SOllOANOR1ISSUEDON..TI()l\I6E~"COl~SI~~'lOb WASCONSENTGfWjTED' <br /> <br />o ~PlKNOI'IN I 0 Y~S IX} ~o I 0 YES <br /> <br />1';'J~1fft IPHY!lIClMI, CORONE~ 8 PHVSlC1AN 00 COU~T\' ~TTOI1~EYI IT",.,~ <br /> <br />CITY OR TOW>' <br /> <br />ST"TE <br /> <br />III <br /> <br />III <br /> <br /> <br />~N(l <br />( <br /> <br />1- o"TEFI~D8;~1 i. <br />