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<br />.. <br /> <br />'! <br /> <br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA STA'.I:'E '. <br />Di"'~.ARTMENT 'OF HEALTH. IT CERTIFIES THE BELOW TO BE A TRUE.,g:O~'t<,' <br />~-OnN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMEN'f" OF: 'llE,^t~l}_ , <br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITO~)"FOR'-.""" <br />",. t 1". <br />VITAL RECORDS .__ <br /> <br />DATE OF ISSUANCE <br />JUL 1 2 1985 <br />LINCOLN, NEBRASKA <br /> <br />200604245~jl-llfN~J,:' .. <br />STANLEY S. COdl?EI(;I?me'C':(DR: <br />BUREAU OF VITAL STATI~t~CS <br /> <br />. '12.506-48-1503 <br />',lESIOf....a STAn COUNTY <br /> <br />;1.,... Nebraska ,_. Hall <br />. ,_ 'ATHU NAME "., <br />=1. <br /> <br /> <br />,'" <br />.~ ,DK!ASEO NAME <br /> <br />STATE OF NEBRASKA-DEPARTMENT OF REALm <br />Bureau or Vital Stalulie. <br />CERTI FICA TE OF DEATH <br /> <br />-: <br /> <br />,...., <br /> <br />...-. <br /> <br />.."" ..:lN4-. 0 3 3 7 9 -l <br /> <br />LA" <br /> <br />DA.TE Of DEA.TH (MoONT", D.a.". Y!,~,jIt: <br /> <br />I. <br /> <br />127"MSrctr197tr-- <br />COUNTY Of' DEATH <br /> <br />~ '" ".....! <br /> <br />Po. Hall <br /> <br />. If NOt" IN I!ll'MII, OIYl SfMlf ~ "'''''.1. <br />,J <br /> <br />. <br /> <br />lit. <br /> <br />14.. Grand Island <br />_ "'" MOTHU <br /> <br />E. Nebraska <br /> <br />,tU, <br /> <br />M'DOlI <br /> <br />"'" <br /> <br /> <br /> <br />.11.. B <br />_ "WAS DfCWID M.IN U.$. AllMID PQlCU? <br />I cv... _.. ..u-) (II _ ..- _...4 ~ 01 _, <br />, No <br />'MT I. DEATH WAS CAUSED ''1', <br />D... <br /> <br />Risden 's~. <br />INIOIlMANT - NAJAI_ .fL"'IONSH~- _"ING AOOIfSS <br /> <br />Anna <br /> <br />Penner <br /> <br />u,"n oa _,'.D. NO.. (Ity 0<< row.... $f4"~ 1"_ <br /> <br />Risden <br /> <br />420 E <br /> <br />Grand Island - 68841 <br />" <br />H.-wI'H ONU. ... DI"," <br /> <br />(.., <br /> <br />. ~ <br /> <br />If YES .ltl "ND'NOI COH. <br />1f~"O IN DlTI..IN....O (:At,fM <br />()f DIAl" <br />1"- <br />HOW INJU.Y OCCU..ED c ._. _..... O. INIUn IN '''If I 0<1 '''If ". ..... I., <br /> <br />,...., 'H. f"-.. W.... '"III A <br />onGNANC'I' IN THI ,All , MONTH$T <br />YI$ 0 ItO 0 <br /> <br />llk. <br />lOCA nON <br /> <br />M. 211. <br /> <br />c Inln 01: "'_0. NO.. CI" 01 'OWN. .'." J <br /> <br />tit. <br /> <br />lit, <br /> <br /> <br />'CHTIPlCATlON- _ .... .IAI .... <br />~ "'IYJIC;IAN; <br />J I AmNo.tt 'H' <br />I- 21.. "'CI"NO '.0.. <br />i CBTlPICATION MEDICAL ....,. COltONf OH '"I ...... Of _ <br />_'~' ..........hON 01 _ II()OT AHOlo. 'M .....VUllOA'lON, IN ., or....ION. <br />~,~, DlAfM O((uHtO 0.& ..... DAft AHO Out 10 ntf CAUMIt.. ,'..no. <br /> <br />DIG." 0. tIT" <br /> <br /> <br />STAff <br /> <br />CITY O. row.." <br /> <br />Aurora <br /> <br />Nebraska <br />NE -68818 <br /> <br />'.. . <br /> <br />. ... ~ . <br />