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<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANPtJl!M~NJ;ERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINA14iEQt)!M)~~ WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAr..Jl:f!E$j~----' -~;,~ifl~H IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS,?-"2'-..,-~-ii:.-'cZffi.'f- .~:.
<br />.; ,:;"~ ',r~;:/: . -..' -" ~~
<br />
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<br />
<br />
<br />
<br />200607498 ~c~P~
<br />,.gtST~R
<br />HEALTH__ .d~ERc~~ES
<br />
<br />STATE OF N!DRASKA - DEPARTMEH'J OF HEAL. TH'.... ,..:~=",':ti~~~~j;,;1t1::3' 0 0 7 C' 9
<br />IUAEAU OF mAL lSTA.nrncs ,i' . . /;';;.".,:c,c- 7. :
<br />ceR11FICATE OF DEATH '~.. ,;: ..:~~>_~j .
<br />!4OOI..E LAST 2. /lEl( ? MTE Of :.lEA '1M ~ OIly, YwI1
<br />Gay Bomstad Femet le ,Janl.la 2, 1993
<br />s.. AGE . LUl ~ a D.lrE OJ- IlI'lfiI /fIMIh. OIly. f_
<br />lY"" 51>. IlIOS. DAYS 6c.loIOUfl8! _.
<br />58 : : I July 24, 1934
<br />
<br />
<br />~
<br />
<br />DATE OF ISSUANCE
<br />JUL 1 8 2006
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />f,' I, t>llCiOEHT . ItI!liHi -- FIAST
<br />
<br />Jacqueline
<br />4. CITY .\NO STATE OF-1Iim\; (1I1lC1" u.s.4-. _lIDIItWYI
<br />
<br />Bryant, South Dakota
<br />CUAITY NUM8Ell
<br />
<br />
<br />(fI1IQ/ ........,." g/Wl_ w num/)fr)
<br />
<br />507 North Car'ey
<br />... 1lI!81OEHCE - STATE lib cWHrv
<br />
<br />Grand Ie-I,. -_. ,.
<br />\It.:. CfTY. TOWN OA lOCATlON
<br />Grand Island
<br />
<br />10. ilIACE " l.,g.. _. &lUll, _1nclicII. II, AHCE8TRY I.,g.,......""........ aer....... .".1
<br />~.I f~} . (SpiM:/fy!. . 0 '
<br />wn~te American '<' Married Allen aomstad
<br />141.USlJJ\lOCCUPATION(G/I'I'lrllldd__d\Wi1gnlOal l1!l-.1l'fIQIi~lNO\.!lUR'I", ,.lS. ~..,aTrlll _. .~._"._< ~-'''''.dll:llld_
<br />d-*/"9__II~! ""'). l?UY i:)Com:.s 0;' Amerlca. ~811 E..~",s-.~IO-I21 I CoIII8I (1.4 or s.j
<br />Off.lce Manager 0.. Overland Tra~ls Counc~l ' . i 12th :
<br />I$. FATl-IER _ NAME FIIIST NlDOI.E LAST 17, 'MOTHeI'I- ~AlOllN HM'E FtfIST MOOlE' lAST
<br />
<br />
<br />Norma Haugge
<br />'~1lll:fl OIl A.F.D.. 1<<),. ctrY CIA TOWN. $T"TE. DPl
<br />
<br />Parmer
<br />II. 'NAS OacEASI!(; EVER IN u.s, ARMED FORCES?
<br />""-, .... QO'.....1 I I-I"". glve - .rid -. III MMcNI
<br />. No
<br />20&. BlI!\Ml, Cr_._od. 2Ill>. DATE
<br />~
<br />Burial
<br />
<br />6, 1993
<br />~/J1
<br />
<br />Hen Bomstad 507 N carer Grand Island, NE 68801
<br />2Ol:. ceMETERY ORCAEMATOFiY. N"~E l!Od. ~OCATIOH errv Ol'lTOlllN . . STATE
<br />
<br />Westl!lwnMemorial Park ~raTld Island, Nebraska'
<br />22. FUNERAl HOWi - NAME AND AOORESS lSTReET 011 R.F D. NO.. CItY CIA TOlIloN. STATE. 21Pl
<br />
<br />A fel Butler-Geddes
<br />(ENTER ONL'( ONE CAUU PER UHE FOIl 18). ib), ANO fell
<br />
<br />
<br />None
<br />.......aI_.... _....
<br />
<br />-----
<br />
<br />
<br />OTHER SIGNIFICANT CONlllTiOMS - Co/IdIlIoRI _no '" _ td noI'-
<br />!''''FiT
<br />.
<br />
<br />2S. WM c.afJE AEFfJlIIEO TO MEOICAL
<br />EllAMiNEI'I CIA mAONEIt"
<br />._~YAI....,*" Yes
<br />
<br />~, INJURY AT WOfll( fieI. f'l..llCE Of INJURY. AI_.ltIml, _1KII>ry,
<br />(Sp<<:iIy r..... '*" _J - oIb buildlnD. 11II:. ($ltIeIlyJ
<br />27,.. OATE Of DV.TH (Mo.. Dtry. rr.)
<br />
<br />$THfET OR R.F.D. ioto.
<br />
<br />CITY OA ~ au.1i:
<br />
<br />
<br />(11Io Dty, frJ
<br />
<br />!2IIl. Tq,If OF IlEATH a p pro x .
<br />
<br />I 6 : 00 A ..
<br />2Icl. PROfoIO\.ItlCED 0iAD (HOcrJ
<br />
<br />I 11 :20 A..
<br />
<br />2te. !lilT'!: SlGNfD {/oI(},. o.Y. frl
<br />
<br />o YEll ~
<br />
<br />NE
<br />Grand Island Police Department, Grhnd Island,
<br />
<br />1._ !lIITEFUJAN7 10031
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