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<br />1." .. .~. ..'
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTHANtH:WUAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPYOF THE OR~~L"FitCO~~~fILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL.BfAtrSTIC$.;$EC~~~HICH IS
<br />
<br />::;::~:::ErroRY FOR VITAL RECOROS. "';~cJ~
<br />2 0 0 6 0 5 7 9 6, ~ANi.EY~"""PER
<br />. ,ASSJ..S1W!t SIA.TJtFiEciiStFlAFI
<br />~LJfJ~NDfI:i-~~-'o~FlVICES
<br />""=.':":- ..~' '.~ n": ~ _
<br />
<br />JUN 0 8 2006
<br />LlNCOLN,NEBRASKA
<br />
<br />FlflST
<br />
<br />STATE OF NEBRASKA - DEPunlEHT OF HEAL nf'->., .
<br />BUtEAU OF VITAL STATlSncS I i 0. .... - .
<br />CERTIFICATE OF DEATH ~ ,'-1) j-
<br />12, SEX
<br />Male
<br />
<br />89
<br />
<br />4764
<br />
<br />Hall County, Nebraska
<br />-7:~IECowfyNuM8ER-"--- lla. PLACE Qf OEATH
<br />,fl J::t.QMIT[,I,. 0 I'Plli"" tkEfl10ulplliflnt 0 00"
<br />~ 0 Nursing Home 0 Residenc" 0 other (Specify)
<br />.81>, FAClLITY. Name (IftIQ/iIIKMt. gw.__lIUIIdw) 8c. CITY. TOWN OR WCATION OF DEATH lid IN$lDECITY LIIMT~". OOUNTYOF.DEATH
<br />- Grand Island I (~e~s-(HNoi. Hall
<br />S~" Francis Medical Center . Y. .
<br />:!fe.. I'lESlDENCE. STATE ge CITY TOWN OR lOC"T'''", ed. STREET AND NUMBER (fflCiIJd<ng Zip CoM) 1900. _.CITY LIIIllTS
<br />
<br />.: Nebraska Hall I" DoniPh~~' R. Rt. 1 Box 109 . (*it.;-"""
<br />_ 10~ RACE - "(eg., ~r 8lIck. Afn$ri~ Indi",. 11 ANCESTRV ,. g..~, MeXIiQn. Ger""", etc.} 12. MARRt@,NEVER MARRIED, 13. NAME OF spouse (It.... g/WI ~__
<br />! 1Ic.) (SpeiIy) (Sp.dy) I . W!COWI<D. Dr.:CRCED /Sp..c;;Y1 I' .
<br />'___ White L-.- American t)v Marr1.ed , Bernina. Elwick
<br />_'~ usu/ii"6CCUPIITlO'l(CI..k,I1dIlf"",*"<fat>r*""",,:;;;;;r-- 14b.l\lllOOFBU9INESSINDUSTRY --r;s EDUCATION ISooodfwoolv_ClI_u- ,.-
<br />: ot_ifl9nr.. .v~ ;(f'f/iTMJ) I E-.yo< Socondary 1(1-12) I CoIo9t!1-4or~1
<br />_ :E'armer t:'( Agriculure tJ // 18th :
<br />:: '&. FATHER. NAME i'IRST I.lIPPLE Bo 1 t Z LA -.ST .=117, MOTHEt-l. MAlDEN NAME FIRST toIIODl.E LAST
<br />
<br />- Gus Lena Lilienthal
<br />lii. WAS UCCEASED EIIEi'! iN U,S, It EO FO!'CES' 19. INFORM,o,NT . NAME. MAIi.lhG ADDRESS ISTFleET OR R,F,D. NO" CITY OR T()Wtj. STATE, ZIP!
<br />" IV... no, ClI unlr,f I 1M y~.. Si"" .,.. and d_ of ........)
<br />I No I
<br />2Oe. IlURI.01.. C_.RIllIlOIIII, !2Ol). DIITf
<br />I oc....iiOoi A -of 1
<br />Burial ~p~--
<br />
<br />
<br />Sll. M05,
<br />I
<br />I
<br />
<br />
<br />3, DATE OF DEATH (_. o,y. Y-..
<br />
<br />I" DECEiJENT . N^Mlii
<br />
<br />
<br />4. CITY AND STATE OF BIRTH
<br />
<br />--MIDDLE
<br />
<br />LAST
<br />
<br />Bernhardt
<br />(If /lOt in U.S.A" _ Counlfy!
<br />
<br />NMI
<br />
<br />Boltz
<br />
<br />April 18, 1989
<br />
<br />OAVS
<br />
<br />6. DATE OF BlRTH ~. O#y, yootj
<br />
<br />Aug. 10, 1914
<br />
<br />506-44-1725
<br />
<br />
<br />Bernina Bolcz-Wife-R.Rt. 1 Box l09-Doniphan9 NE.68832
<br />2Cc. CtM~TEFt'''' C~ CRE:~,~~-rG;:i": . ~~P.;2 - j 20<:. :"OCATION . Off OR TCMW S"'A~:.r--
<br />
<br />Cedar View Cemetery
<br />22. FUfO(,R!\l HOME. NAME AIIO ADDRESS
<br />
<br />Doniphan, Nebraska
<br />ISTIOf!ET OR RF 0. NO CITY OR 70\....N. :STATE. ZIP)
<br />
<br />Apfel-Butler-Geddes 1123 W. 2nd, Grand Island, NF.. 68801
<br />fENTER ONLV ONE CAUSE PER LIN!: FOR fl).fb). AND (cll .11\IOrwI ~ __~
<br />
<br />--.,..---
<br />
<br />=
<br />
<br />011 /1.:p-
<br />
<br />DUE TO. OR AS A CoNSEQUENCE OF:
<br />
<br />-I ~""L~.q-->~. ,""___
<br />I O~€r, ::C"tr.c~f caHu~TJOijs ,. ~ eontributing to delth but not re:llted
<br />;;OM.
<br />M
<br />
<br />_11____
<br />
<br />
<br />PART III IF FEMAlE. WAS THEAIO A
<br />PIlEGrlANCY IN THE PAsr 3 MONTHS?
<br />
<br />No CJ
<br />
<br />2lIf. IlUJAY AT WORK
<br />(Sp<<//y Y.. /Jt No)
<br />
<br />STF!EfT 0;:; ;:;,1',0, NO,
<br />
<br />CITY OR TO'Ml
<br />
<br /><l1ATE
<br />
<br />2llA. DATe SIGNED Ilia. o.y. Yr.} 12lib. 'lIME Of UL'I1'H
<br />
<br />
<br />~.~i"2- -1tU~ ~~---"''''''' !---..~~ --:-
<br />
<br />27d To lho boll oI01y knowto<lgt. _ OGo",r~ ti.... _......., pIact and duo 1M ... ~ ~ :Ie. On "'" _ 01....__ AIl(l'''' ~1lM. ., ""f opio_ to"'" __ .
<br />i!!! -...(.j _. p"-; ~/ /' Itl" I...... d... AIld"'" -.l_ "'..... r...""l"! .~
<br />
<br />~. 1 t~~~~~llo.l-.__~X~~..l...&(D__, I (Fl~",~.""T'1'e:--
<br />--'1... .....0' ~ ut;E COHTRlilUTE TO ;IiE OEAl H? I30VHAS ORGAN 011 TIS!\"" MN,lTl()iII BFEto; CONS'OEIlED"
<br />I
<br />o VE~ CJ NO ~KNOWN l~-.. ".. d VES ANO
<br />
<br />~ ...." ..t>imi;..a lJI' <;l;,TIi'IfIl IF'HVSlCMI. CO+lONEIl'S PHYSlCm Ol'l COUNTY -'TTOilNliV) IT~ co "ri~l}
<br />
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<br />i~"
<br />
<br />I Th'ane
<br />_13::"~$T~
<br />~ I
<br />I
<br />
<br />Baker
<br />
<br />~ St. Francj._~~_edical
<br />,,_/1.... " ~
<br />,---'~ ;o'U.. .' II n'" t:;
<br />
<br />Cente.1"'.
<br />.,
<br />
<br />Grand Island. NE. 68803
<br />1321> OATl'F'IE!)!!"'~'Sf1"NI {III<J..~'. >'r.!
<br />I AfR 2 6 _
<br />-1._._,"
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<br />Ii Xll W"'S CON5EN7 GAAI.1EO?
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