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<br />STATE OF NEBRASKA
<br />
<br />'- WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HLlMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIWfM.i:R..Eqp~ Ofy,FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST~S1I~S~~ W'fICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. !/Aiff;,~'f;'-~~~
<br />
<br />
<br />DA~EA~/~S~A;~~6 200604655~~~'j~~~:~
<br />
<br />LINCOLN, NEBRASKA ~~L~~~A,isERVlCES
<br />
<br />...
<br />
<br />STATE OF HEMAIKA - OEPARTMENT 01' HEALTH
<br />BUREAU OF VITAL STA'nSTlCS
<br />CERTIFICATE OF DSATH
<br />
<br />95-06663
<br />
<br />I'~"-
<br />
<br />.' CIlV4ND$TATEOl'I!lRT" """"VSA.__i
<br />Omaha, Nebraska
<br />
<br />FI/'I$T
<br />Roger
<br />
<br />UOOOI.E
<br />Allen
<br />
<br />-1'-::soc-~ $K\lM1TY tW~fiI
<br />
<br />
<br />U\$T
<br />Williams
<br />
<br />Ut.oEI< 1 YEAR
<br />50 YO\; D.lYS
<br />
<br />2. llEK
<br />Male
<br />
<br />'.i"'OATEOFDl'.ATlI ,-. 0... ,_
<br />June 2. 1995
<br />
<br />UlWEA , D.lY
<br />50. HOURS MlNS.
<br />
<br />6. o.i\n OF 8lATiI i_.Wi' '_1
<br />June 30. 1943
<br />
<br />liIi f-AciufY-:-iunot
<br />
<br />1/1,,,,_11"'"__"'-
<br />
<br />k. Pl-ACf OF Dl'.ATlI
<br />~~. KJ...... 2!~~
<br />o EA "'-
<br />DOOA
<br />
<br />o Nw""9-"
<br />o f\t:sde1'\(;1lr
<br />o Oh-. ,&,,,,,,1./1
<br />
<br />507-52-4245
<br />
<br />~~!IlIr, LannIng XemorialHospital
<br />.. CIfY TOWII ORlOC"'1CN OF DfAT..
<br />Hastings
<br />
<br />
<br />OFllEIIlH
<br />Adams
<br />
<br />90 AESl~-SrA'l'
<br />Nebraska
<br />
<br />V.A. Hos ital
<br />lAST '1 MOTHEA
<br />
<br />lld STlIl'fTmtlmJMllEIl I~ZIp~ "" ..SiOECIlYIMIT$
<br />· 721 N. Superior St. 6Se,Ol Y.. ~ No 0
<br />o ......l)()Wf:l) 1'3 - OF SI'OV5E {...... 9""-_
<br />o OlIIOACED.. Mary Vasquez
<br />~T1OtoI 1_.....~O'_e_ _
<br />03/ I E_,,,,_IO,'21 Q;jIogo"-4",5-i
<br />o i 4
<br />F1AST MIDOll; ~'" Sl-....:
<br />
<br />'0 'lACE -lOll. _ 1Iw.' ~.._
<br />..1'_""
<br />
<br />Richard E. Williams Jane
<br />- 18.- WAS llECEASED EVE'llN us _0 FOIICE~ vy: 4/27 62 ''''' Iffi'OAMAHT - NAME
<br />
<br />~aYES~)J71i5i66;~;Y:l'3/9l-7/1/9 Mar Elizabeth Williams
<br />'lIb INFOIlIAANT MAIlING AOOfll'SS <STREET OR RF D .,p.. CIlY OlnOWN StATE liPl
<br />
<br />A.
<br />
<br />Galus
<br />
<br />
<br />721 N. Superior Street, Grand Island, Nebraska 68801
<br />
<br />TU &l~EIISf'~ " J/Q'I 2'. lAETt<lDOI'OISFOSlT<QN 1210 DATE \2'< CEUHERY()I>C,*,,"TOI'l' "'_
<br />
<br />- _ If I j I]JBuI;oJ D""""",., I June 6, 1995 I Grand I~lan~~ity" Cemetery
<br />12'~ CEUETEAV C~ CREt.!AT()I>V LOCATION en, CR '0""" STATE
<br />
<br />Livingston-Sondermann F.H. Dc.- 0- L____ Grand Island. Nebraska _
<br />22b FU"",IW. HOUE _ss <sTllEn OR R.F.D 1;0 CITY OR TOWN. STATE. ZlPI
<br />
<br />i 505 West Koenig, Grand Island. Nebraska 68801
<br />~lliATE C-"<JS/i IE"'TER OM-Y ONE CAUSE PI;R lINE FOf< '.. 101 AND 1<11
<br />
<br />8,_ ~~~fb'/,4e
<br />
<br />"".-r--. .. - DuE TO. 00 AS.I. CGHSfOUENCE' ~
<br />
<br />~~~::JnSeIillilO~.s1
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<br />d/~
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<br />rQC2 ~
<br />1nIe-'....~I~~(tNide:alh
<br />
<br />Il>I
<br />Out TO M ~ ... trJf~SfOi.JfNC€ (y.
<br />
<br />11"'"- ....'-:.- ~1;,
<br />
<br />'_.'-~~---------~~'i'::~.. ~M'IO~
<br />
<br />~I iel
<br />or~~ tilGI'1iJF.c~N' COt,ll)ntONS ~ l.:t~ 10,.". 08I11n l:lli nor t~ I PART IH If j:"fUALf WAS lHERE A r.(.lJ ..lUTOPsv ~$) WA. S CASE Rt:Ff~Q TO Ul:0IC~
<br />P....T P"H;t<..llCVI'" THE ."S I 3 UOti'tlS? V'-- (>AM""" C<l COFIOtIf"-'
<br />h~---~~___~.~__~'os.ol Vos n ""Dl2:~",,,.D J ~'"'~ ",,0
<br />26a l 2t"b uAi H: OF lNJ~v ;~ Day Yn j2fk r-IOU~ OF" tNJUR., I ~ Of:SGRJ8E; MOW IftlJUf'!'t OCCURR~t'
<br />
<br />I [J Ac'..... 0 \1-"".... ' I ..
<br />f . 'lI'l !
<br />. 0 ~.,. 0 -'l f?6e ""'UPVATWORl<j '. >6f Pl.ACI;'0I'INJU"V"~nom..,';;:;;-;~..;y~126I>' LOCA;ION
<br />O 0 0 otf".~... '_I
<br />L,.~ t'k~ In'~~: 'r~ ~ 1
<br />,~~L- _"L.
<br />!i!ra o"'-t'r:Of~j",", ;:\6;; r...,;;t' lo'rJ J '.'.t&."l r'A.'t~SKiNED (Me Oar Yr/
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<br />;,~ ~ to - 2_=--.J2J ~_ EH
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<br />! i. ~ )r. ! 2~. (l"1~ Sft"'~Et'J I~I o...t..... "'":-I . f 27.1:" TI'-'EOf DEAtH _ II ~ g 28c j:lAONOUNCeOOE.a.O IMe /Jay. i"TI =1:au. PROl\fOUNCi:DOf:AD rHoti<'!
<br />
<br />~~i~ly.. 0- i-- 2.,5- 'J "~~f~i~ , ~
<br />
<br />: ~~ j , 2~~ lO""'DE>$iofmy"~ ~:t.I,i~fB:l ~"'.~... c ,";?,ot.he ~ I 9 28i OntF'l8baslsQt~.msnallOnand.-otIl\\IC'I$lIgatJ(Jn.lflmYCplnlOnd8alt"t;)cGUIl'eoal
<br />~ a..J'~ C!:~~j ~tnIG,./ t.) ~, tN1 fime. da2e and place ltnd UuIt to tht cau!itl~18tIted,
<br />III __~""'~.'l ~ _..:.. ~ ~ ~ rSI ~..-ea"",T.
<br />1:>9 (>'0 T06ACCOllSE COOT un; fii'.",~? 00.' HAS OAGA'" OR TISSUE OO"'ATl<:JI',lIlEE'" CONSIDEFlEO?
<br />
<br />'.~: 0 vES ,'<0 $ U'<<'IOWN "" ---KI VES 0 NO
<br />
<br />31 "'AIoO[ AiiilAi'iDRess OF ,:?TtF?lP11vrw.. ~R'S PHVSlCIA'" OR COU"'TY ATIO,"",EYI. /T_ '" PMlI
<br />
<br />~..__"_J6/~~~_ .~_~?~e::--:-c . /;"/.1//,1#
<br />32. 'll:GlStlWl
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<br />STREE"l OR R F 0 NUo~~"il'7ORrOWN-
<br />
<br />SiAn
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<br />2tlb T1.... 01' 01'...,..
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<br />3a.b WAil CON~T CJ,AANTEO"
<br />~ ~YES
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<br />DNa
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