|
<br />N
<br />is
<br />is
<br />0)
<br />S
<br />-...J
<br />.j::>.
<br />-...J
<br />.j::>.
<br />
<br />
<br />IS
<br />-
<br />.
<br />
<br />~
<br />q:J
<br />c:
<br />Z
<br />C
<br />en
<br />..
<br />
<br />~.....~
<br />c:;:
<br />C)
<br />N
<br />~
<br />
<br />We
<br />~
<br />
<br />r-..;,
<br />(;,~.::::.;:a
<br />=
<br />~.=i?
<br />
<br />~~
<br />(")cn
<br />~:x:
<br />
<br />......,'.J
<br />r--~'
<br />~ t~~
<br /><.o,~;.:.~
<br />o~
<br />"1
<br />
<br />t'
<br />
<br />....4=
<br />Nt>
<br />Ul
<br />
<br />
<br />V\
<br />U\
<br />o
<br />
<br />-a
<br />:3
<br />
<br />C}
<br />rt'1
<br />r",
<br />o
<br />(Jl
<br />
<br />---,ESCRIPTION:
<br />
<br />Lot Five (5), in Block Twelve (12), Claussen Country
<br />to the City of Grand Island, lIall County, Nebraska.
<br />
<br />WHEN THIS copy CARRIES THE RAISED SEAL OF THE NEBRASKA STA TE DEAvifiif::~':JlE HEAL TI:I.
<br />"CERTIFIES THE BELOW TO BE A TRUE COPY OF AN ORIGINAL RECORl1"'iiiL,m'WifH"'Fii1i..STA TE
<br />DEPARTMENT OF HEAL TH. BliREAU OF V"AL STA TISTICS. WHICH Is~teGAl.t~iiBY FOR
<br />
<br />:~;; ::;::::~CE ~.1~.~:~r~'" ~_". --', '~~'.\~.~i~".,
<br />~:~~, ?c~$Ti~' jy~) iRJi1PER
<br />NO V 4 1998 2 0 0 6 0 7 4 7 4 "MSiSIA/IlT ST. TE IlimsiiRAR
<br />LlNCOLN.-NEBRASKA NEBRA~ ~~T~1JF!!fAL TH
<br />'97 STATE OF NEBRASKA- DEPARTMENT OF HEALlH AND ~'~~:~~~ SUPPORT
<br />VITAL STATISTICS ......,...-
<br />CBRTIFICA TE OF DBA TH
<br />
<br />,. OlOClOOENT - NAMlO
<br />
<br />MIOOlE
<br />
<br />lAST
<br />
<br />2. SEX
<br />
<br />3, DATE OF DEATH IMonth.o.y YUt}
<br />
<br />October 23, 1998
<br />6, DATE OF BIRTH IMon",OOy. Yur)
<br />
<br />FIRST
<br />
<br />Harvey O.
<br />4, CITY AND STATE OF BIRTH IffflO/it! USA" n,,,,"countryl
<br />
<br />Larsen
<br />5a, AGE - Lut Birthday
<br />ly,..1
<br />72
<br />
<br />Male
<br />UNOER 1 DAY
<br />50. HOURS' MINS.
<br />
<br />June 18, 1926
<br />
<br />
<br />UNOER 1 YEAR
<br />!;b. MOS, DAYS
<br />
<br />Boelus, Nebraska
<br />7, SOCIAL SECURTIY NUMBER
<br />
<br />Bo. PLACE OF DEATH
<br />HOSPITAl,
<br />
<br />Inpatient OTHER
<br />
<br />00 NurSinQ Home
<br />
<br />o Residence
<br />
<br />o Oth8, (Spec'"''
<br />
<br />o
<br />o
<br />o
<br />
<br />OOA
<br />
<br />506-28-3427
<br />
<br />Iltl, FACiliTY - Nome
<br />
<br />(ff not ",.Ii/uIiOn, gi... $If HI ond n"",wl
<br />
<br />ER O_lIen'
<br />
<br />St. Francis Skilled Care Center
<br />60, CITY. TOWN OR lOCATION OF DEATH
<br />
<br />
<br />ad. INSIDE CITY liMITS
<br />
<br />Grand Island
<br />90. RESIDENCE - ST ATE
<br />
<br />9<1 STREET AND NUMBER IlncllK/1og Zip Code)
<br />
<br />68801
<br />
<br />13. NAME OF SPOUSE /ffwiltl, rJI"""'1tWt no""'l
<br />
<br />Y.. ua NO 0
<br />
<br />Gladys Schlieker
<br />
<br />19 15. EDUCATION ISpoc,lyonlyh;gllU1gr""o""",pWdl
<br />EI\fnAl"-~.P' _0'1' 10-121 ColIego ".4", 5-1
<br />lL rears
<br />FIRST MIDDLE MAIDEN SURNAME
<br />
<br />Nebraska
<br />
<br />10. RACE. fe.g.. White. Black. American Indian
<br />O1<.IISpoelty)
<br />White
<br />
<br />U.S. Postal Service
<br />
<br />
<br />16. FATHER. NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />17. MOTHER
<br />
<br />Lawerence
<br />
<br />NMN
<br />
<br />Nellie
<br />
<br />E.
<br />
<br />Gladys Larsen
<br />ISTREET OR RF.D NO" CITY OR TOWN. STATE. ZIP)
<br />
<br />Ne. 68801
<br />
<br />2,.. METHOD OF DISPOSITION 210, DATE
<br />
<br />21e CEMETERY OR CREMATORY NAME
<br />
<br /> (") (/) c:::> I
<br /> 0 --1
<br /> c:: l> N
<br /> :z --1
<br /> -i .m
<br /> --< c:> ~
<br /> c>
<br /> 0 ..." c:>
<br /> ..." -
<br /> ~,.. en ~
<br /> ....
<br /> ::r: 1"'1'1
<br /> ):0. m c:>
<br /> r ;n
<br /> r 1>0- -..J 3
<br /> en
<br /> )<; --c l
<br /> )> -..J
<br />--
<br /> r;p ...r:: g=
<br /> -U!f
<br />View Addition \~
<br /> ~
<br />
<br />go INSIDE CITY liMITS
<br />
<br />Blair
<br />
<br />o Cremation 0 Dona.llon
<br />
<br />~Bu"OI OR.movol Oct. 28, 1998 Westlawn Memorial Park
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />
<br />Grand Island. Nebraska
<br />
<br />Island, Ne. 68803-4050
<br />IENTER ONLY ONE CAUSE PER liNE FOR 1.1,101, AND lell In'....1 OolwOOn on..' and deo'"
<br />
<br />
<br />{O)
<br />DuE TO, On AS A CONSt:.OUE.NCE ()F
<br />
<br />lei
<br />PART OTHER SIGNIFICANT CONDITIONS Conditions contritM.Jiing 10 r"f: deatn but I'KJt related
<br />
<br />"
<br />
<br />250.
<br />
<br />260. DATE OF INJURY (Me.. Day. Yr,) 2$e. HOUR OF INJURY
<br />
<br />D Accident 0 U!'1oetermined
<br />) 8 Suoc;de 0 P.nding
<br />
<br />260. INJURY AT WORK
<br />Yes 0 No 0
<br />
<br />HomiCide
<br />
<br />trwe$!lg.ation
<br />
<br />x ?~
<br />
<br />Interl,/al between onset and death
<br />
<br />l"t8r\l81 betWeen onHI and deal!"I
<br />
<br />
<br />27_. DATE OF DEATH (Mo.. ooy. YO
<br />
<br />26a. DATE SIGNED IMo.. ooy. Y,)
<br />
<br />2Bo TIME OF DEATH
<br />
<br />M
<br />
<br />X October 23, 1998
<br />
<br />E~i
<br />n~~
<br />B~Si
<br />.e~g
<br />'-' ~
<br />
<br />2Be. PRONOUNCED DEAD IMo. o'y, Yr,}
<br />
<br />28d. PRONOUNCED DEAD (Houri
<br />
<br />M
<br />
<br />
<br />270. DATE SIGNED IMo.. o,y Y,)
<br />
<br />27< TIME OF DEATH
<br />
<br />M
<br />
<br />28e. On Ine basis Of examination and'or investigation. in my opinion deAth occurted at
<br />the time, elate a.nd place and ChJ8 to the c:.use!s) stated.
<br />
<br />
<br />30,0 WAS CONSENT GRANTED'
<br />X DYES ~o
<br />
<br />30._ HAS ORGAN OR TISSUE OONATION BEE
<br />Y DYES
<br />
<br />31, ~ANO ~OF CERTIFIER IPHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY I !:'-"~ (Y Pdnl!
<br />)r John A Wagoner Jr MD, 800 Alpha Street, Grand Island Ne 68803
<br />
<br />320 REGISTRAR
<br />
<br />
<br />320. DATE FilED BY REGISTRAR (1.'0" Day, Yr.)
<br />
<br />NOV 31998
<br />
|