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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGIN~~tjfjli:i:(fN:1EJI",E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL sT~7[tiiTtC'$'S~Tti1iJ~#ffH IS
<br />
<br />:~:~::::~TORY FOR VrrAL RECOROS ~l.~~R
<br />JUL 06 2006 2006066 81 A}iSIS(ANJ'STATER~G;S1jiAR
<br />LINCOLN, NEBRASKA . HE~LTH"A.JtjtJ #l;JAfA-NSERVlCES
<br />":. _:. ~7:. ,.- ,:,.:: ",: ~.r;'".": ,.;.." .:: ,~-
<br />
<br />FIFlST
<br />
<br />STATE OF NEIAASKA - DEPARTMENT OF HEAi.lH
<br />BUREAU OF VITAL STA11SlJCS
<br />CERTIFtCATEOF DEATH M 41",0
<br />
<br />Mi~s~er -r ;ema1e
<br />
<br />92
<br />
<br />04514
<br />
<br />11. OECEO€NT ' "ill~
<br />
<br />'.UODl~
<br />
<br />I J.. DATE 01' OUT'H ..... 0.,.. v_
<br />
<br />Mar aret
<br />4. CITY IINO STillE OF BIRTH {I( cOI In U.S.A. ".,.... cOUIllryj
<br />
<br />MOl::rav, Nebraska
<br />,. SOCIlll SECU/;lTY NVMllE:R
<br />
<br />.Jane
<br />51. IIGE . l.. lili<1nday
<br />IV,..:
<br />68
<br />
<br />Sb. MOS ;
<br />
<br />
<br /><MVS
<br />
<br />So HOlJIW
<br />I
<br />
<br />we
<br />
<br />April 15, 1992
<br />e. OATE OF fIlRTtI ___ 0.,-. Y_
<br />
<br />507-32-8854
<br />
<br />to
<br />
<br />
<br />Aug. 20, 1923
<br />
<br />!la. PlIIce Of Deli TH
<br />
<br />~
<br />
<br />o~
<br />
<br />81>. FIICII.ITY . NImeI
<br />
<br />{If rIOt irlStliUhOfl. ~ !t1HIIIIll1 """'*'1
<br />
<br />lie. COl.IffY OF OfATH
<br />
<br />St~ Francis Memorial Health Grand Island
<br />
<br />9ar::;::TE ~9b c;:~l 9c ~~~:~~;:;:ld 2404 N. Hancock .. ~o:.:=-
<br />
<br />10. AACE. \0.0.. WIIi'... ~k. ........"'on Ind>.... 11 ANCESTRV (...p..,.....jrl, _"'"", o..m...., ....) 12. ~,NE\IeR M.olRR!E(l. 13 IolN.IE OF 8PO\I4lE. lit... .........._
<br />....,{~~.I (Sprt;ily) Ib WlOOWUl, DlVORCEO ltip<<t/yl
<br />W\~.. , American 0 Married ,j<"rm1J1d Miller
<br />14a.U~- ~-;::-~. .N-iGiwkNofwCrl<<10,,.<iur'rl(J_ lOb. KlNOOff'USWESSINOUSTRV p-~ ~n..r"nnN _.. ~:--:-_ ....
<br />
<br />of ~':J~ ::.'ftiHousekeeping \\\..f\ V.A. HOB ital ~'3\ liSf.J<.*Y.'21 : c..,. 1'-4 d-1
<br />
<br />16. Flln: FIRST MIDDlE lIIST 17. MOTHER. loWOEH _ FtfIST YIOill.i: LASr
<br />
<br />
<br />. Alvin
<br />Ill. \II. S DeC~D EVER IN U.S. A_O FOfl(" .,'"
<br />IV;;; or unk.) I (H yea. 9'110 - and - (I seMe")
<br />
<br />2!l.. BURIAL C'_,_.I, 201>. OATE
<br />Oon""".
<br />rial
<br />R. S1GNA""UAE & llCEN
<br />
<br />1$. INFORMMiT. NAME . 111~ IIOD!'lESf
<br />
<br />
<br />2Od. l..OCATIOW
<br />
<br />ClTYOAT~
<br />
<br />lIlT4lE
<br />
<br />fSTIWOT OM Rl' .0 NO.. CITY Oft rooMi, ST41E. ZPl
<br />
<br />1123 W. 2"'ld
<br />
<br />
<br />........----
<br />
<br />/qr1
<br />
<br />.v
<br />
<br />........----
<br />
<br />:)UE TO. OR AS II CO"ISEOUENCEOF'
<br />
<br />-------
<br />
<br />~I .
<br />O. T'*Fl S:GNIf:CIINT CONOf.TIONS ^ Contii/JcN eonvWng 10 .,..., but net ,_ ==:AAT III If fEMAlE. WIIS TI1f.AE A
<br />P~,RT Il. d, .', . CA ~ ,. ...-- PHEGN~Y IN T'* PAST 3 MOlIIn-ctl?
<br />7~ "P'NU1 au.. ('1 ) \ V.. C
<br />
<br />211.. 1.C<"?ENT, SUICIDE. ~ UNDET , 2eO Oil TE Of INJURY fMo ,Day. Y,! j 2lI<: HOUR OF If<JlIfO' 2&1. 0E$CRIIlI; tIOW INJURY <X:CUAIlEO
<br />llR P9Il;llHG lNVESTII3ATION fSpttc1tyJ
<br />
<br />
<br />2ile. I'IJURV liT WORK [2ef PLACE of INJCRY.1Il home. firm, _ IIClOry SIREE.l ~ R:F'~-
<br />(~ YH Of NO) I ollie<' WldOI'1Q t1\C (Sp<<!Iy)
<br />
<br />~
<br />V. OIlTE OF DEATH (Mo.. Ooy, YrJ
<br />
<br />. 4 - f'f"'t~ I
<br />
<br />i~ m.OATESlGNEO IMo,OlIy.Y'1 l27C TlMEOFDEIlTH ,I~;.I; 2llcPflONOUHc-eolJEllO (MQ,~Y'I
<br />
<br />Hit 4 -/}4L I 9:54 P.. I iio
<br />
<br />! Vd To... bM: <JI m-f ~. ""... oce"",od'" "'" lime. ~ and ~ .nd """ to... ~. g ~ On... _ <JI_ _10'. 1Ll j.11"" ...,. _ _ _.
<br />..... ~I_. II.. .. "'_.__pio,ce__IO"'~_
<br />. and T~ lJ..(IjI).. vf\. 'yr.... _ T~
<br />2k. DID T06ACCO USE CONTRtllUTE TO THE DeATH' JO;o HilS ORGAN OR TISSUE DC:lWI lION BUN COI<ISIOEREO' JOb WAS ~ ~
<br />o VES NO :J u..KHOWN 0 VES Il\~ _ ;:) YES
<br />J'. NAME ANO mOAESS OF Ct:"l!T\FIER (PHYSlCIIN. COROHER'S PHVSlC\N 011 COUN1Y An~E'i1 (1_ 0/ PtIttQ -
<br />
<br />
<br />2-'. AUToPSY
<br />~Y!/'~
<br />
<br />2).. W4S CA<< l'II!Ft!NIED m ~
<br />~-C:~a
<br />
<br />CITY OR T~
<br />
<br />S1Ali:
<br />
<br />2lla OA TE SlGNEO lMo.. '-"Y. Yr!
<br />
<br />... TN[ OF DEIITtl
<br />
<br />_~DEAD ~
<br />
<br />.. -
<br />
<br /><.,
<br />
<br />Anne Me
<br />
<br />
<br />Grand Island, NE ~
<br />
<br />68803
<br />I:~. Ti: FlUiO IJ't REGlSTfW! f/tIt>. a.,. YrJ
<br />
<br />.-APR 2 2 S92
<br />
<br />:fl.. REGlSlAAR
<br />
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