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<br />Lot Twenty One (21), in Block One (1), in Meves First Addition to the City of Grand Island,
<br />Hall County, Nebraska
<br />
<br />STATE OF NEBRASKA...1
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUM/!N SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAI..,J!JECQiiii l:iiimEwITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlftnPS':$Ec..i1ffii.--~1tH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS'~~=:=(i/f~ \\
<br />
<br />
<br />D~~EGO~ '~S~AO~~E JV'7<r]f4N~lyicJJ;~
<br />AS~ArtT ~TATE REG~m~R
<br />LINCOLN, NEBRASKA 2 0 0 6 0 7 5 4 5 HEALW ANPJ'-t1!~~'$fiFlV~C;ES
<br />~{"~' ~f' "~"_"'"~'i:';", '~'.' :~~:~',\ .~,{~':'-
<br />--.--
<br />
<br />STATE OF NEBRASKA-DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH j.l: ';,
<br />
<br />86 02022
<br />
<br />
<br />DeceDENT -NAME
<br />
<br />M
<br />
<br />lAST
<br />
<br />FIRST
<br />
<br />Elwin Everett
<br />RACE (..g., Whit., lI"ck, A....ric"n OIIGIN/DUCENT (.'ll.,ltalio.., M..ieGn,
<br />,..di..n, .IcJ (Specify} G.'lIIGn, .Ie.) (SpOKify} I.
<br />-4. White 5. \11
<br />CITY AND ST"TE OF IIITH (If ....t ;.. U.S.A.,
<br />noma ItOUft"',,)
<br />
<br />e.
<br />sOclACSECURITY NUMOER
<br />
<br />1.. '1rand Island
<br />IISIl)t!NCE -STATE COUNTY
<br />
<br />
<br />Hall
<br />
<br />McArthur
<br />
<br />MI
<br />
<br />Budd
<br />
<br />Hall
<br />
<br />Kathyrn NMI Wei bert
<br />INFOItMA"'T-NAME-IlftATlONSH/P-MAlllNG ADDRESS (STlUT 01 l.f.O. NO.. CITY ~~TAn. ZIP)
<br />
<br />19.Evelyn Hall,Wife,652 E. McArthur~ Grand Island, Ne.
<br />CEMETERY OR CIEMATORY - NAME lOCATION CITY 01 TOWN STAn
<br />
<br />20e!lestlawn Memorial Park 20c1. Grand Island, Nebraslca.
<br />fUNERAL HOME-NAME AND ADDtfSS (STlEET 01 l.f.O. NO.. CITY 01 TOWN. STAU. ZIP)
<br />
<br />NMI
<br />
<br />1.
<br />WAS DECEASF.D EVER IN U.S. ARMED FORCESl;
<br />~:~. .y;~.~TUwo;id' w~r.'fI"4Ii)/12~ :
<br />
<br />IUR'A", C,..,oti"n, Removal 011 T
<br />
<br />
<br />68801
<br />22.Livingston-Sondermann, 505 W. Koenig, Grand Island, lIE
<br />O"'TE I N (M... D.." Yr.) HOUR Of DEATH
<br />
<br />.ri
<br />li~
<br />Ara
<br />J'i
<br />,!!
<br />
<br />Ub.
<br />PRONOUNCED DEAD (H..ur}
<br />
<br />2.....
<br />PRONOUNCED DEAD
<br />
<br />M
<br />
<br />2Ac. -4 _
<br />
<br />"" the bcnit .f .".,Moti.n tuttJ/o,. in"ltfIQt(Oft~ in "'J opinion "eo", occurred at
<br />the ,19M. do.. oncl ploc. ollod ~II. to tho COUg(l) ..oted_
<br />
<br />Grand Island,
<br />
<br />Nebraska 68803
<br />DATE RECEIVED BY REGI TIlAR (Mo" Do" Yr.)
<br />FEB 1 U 1986
<br />
<br />2610.
<br />
<br />----,...
<br />I n.,~,....... ..., Oft. ,ci.....,,.
<br />: .. L
<br />' y"", ......
<br />
<br />tnterw:lll h..-w..n Oft.., oftd d_1tt
<br />
<br />*'~/ ~
<br />
<br />~ -
<br />-~
<br />
<br />J+ }-s- ~
<br />
<br />1.....""'1 between; Oft... ond d..th
<br />
<br />(d
<br />P.uT
<br />II
<br />
<br />
<br />AUlOPSY
<br />(S,...;f, V.. ,,, No)
<br />
<br />v..O IflrEl-' 21. No
<br />DESCIIIE HOW INJUIY OCCUllfD
<br />
<br />WAS CA5I IEfEI.EC> TO MEDICAl
<br />EXAMlNEI 01 COIONER
<br />($p.-ci" ,.. 0' No) N
<br />29. 0
<br />
<br />300.
<br />INJUIY AT WOK
<br />(1-", V.. or No)
<br />
<br />JOb. 30e.
<br />'lACE Of IN}URY A' h_. 10"", _t, I.....,.,
<br />elf,.. bu;lc/;ftl, .... (Speci',)
<br />
<br />3Od.
<br />
<br />ST!EfT 01 l.f.D. No_
<br />
<br />CITY 01 YOWN STAll
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