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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 ORIGINAkRECdiifJ.01tFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT!8T.JCS~-W#ICH IS
<br />
<br />::::~::~:TORY FOR WAL RECORDS ~l~ER
<br />AU G 2 1 2006 2 0 0 6 0 7 7 7 2 ~SSISTANT STATE REGiSTRAR
<br />LINCOLN, NEBRASKA HEALTHAND-HUMAN-SER~icES
<br />
<br />- - -
<br />
<br />STA1EOFNE8IASKA.DEPAJt.NENTOF=~A~~SER.VJCESFlNANcUNDSU1j3 07391
<br />CERTIFICATE OF DEATH
<br />:3 DATE OF DEAlH ,Monttl Ottv VIMf,
<br />
<br />F"'ST
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<br />I.lI000E
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<br />l~S'
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<br />~ SEX
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<br />i ' D~cweNl, ~I.IE
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<br />~ Patsy Lou
<br />I' CITv ANO STAlE Of GIRT... """,..USA _~I
<br />
<br />!; Columbus, Nebraska
<br />;; 7 SOCIAL SECUIlTIY NLlI.IBEIl
<br />
<br />~ 507-34-5472
<br />;;! eo FA~ILlTV - N......
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<br />1"1"I
<br />.... Be CITV TOWN OIl lOCATION OF OE.lT"
<br />
<br />:::t L Grand Island
<br />~ !~. RESIDENCE - STATE
<br />I
<br />CI'J L Nebraska
<br />~ 10 RACE - :..g.. w~" a.... AItIlIhCII1_0
<br />:5: ",ci'S_.tvl White
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<br />June 27, 2003
<br />fi OA1E Of alllTH ,_ 0.., 'Uti
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<br />Female
<br />UNOER , O~Y
<br />5<: ><OuRS I.IINS
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<br />George
<br />511. ~Ge . last _.
<br />IV",-,
<br />70
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<br />""'DEll , VE~R
<br />:it> I./OS PAVS
<br />
<br />February 14, 1933
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<br />Ila PLACE OF PEA TI'
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<br />E'R~I
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<br />Re$IMonCe
<br />
<br />Otno. ,~',"
<br />
<br />St. Francis Skilled Care Center
<br />
<br />
<br />III 'NSIOE CITV lIMI;l a. COONTv ()< DEAf"
<br />
<br />Y.. IX] No 0 Hall
<br />9<. CITV, TOWN OIl lOCATION 90 STREET ANO NUl.lal'~
<br />
<br />""141'9"; co<!.!
<br />
<br />! * '..SlDE CITV lI..TS
<br />
<br />American
<br />'.b ~I"O Of BUSlNI'SS INDUSTRY
<br />
<br />i Veo flU No 0
<br />o W'DOWED i 1 J NAI.IE OF SPOUSE ,H w'" "''''''-''''''1
<br />
<br />DlVORCEO' Ro, Geor~e, Sr.
<br />, ,~ EDUCATION ,Soo<: ty 001, _ll'-'~'
<br />~9t'h''''Gsrade 0 '., COllege""""
<br />
<br />.-IIlS T ""DOH - I.IAIOEN SLlIlNAI.IE
<br />
<br />68803
<br />
<br />'" USLlAlOCCUPATION /G,..t"ll111f_"""tNm9""'"
<br />oI_H>gIAV,_d_1
<br />Homemaker
<br />
<br />
<br />Sr.
<br />
<br />lfi FATHER - "AMI'
<br />
<br />FIAST
<br />
<br />MIDDLE
<br />
<br />Clyde
<br />18 WAS DECEASED EVER IN US ARMEO FORCeS'
<br />IY", 1\0 Ot unl...l 'If yes. QiW _.r and dates of MI'\I1Ce&)
<br />No ------
<br />1'1t> INFOFlMANT MAILING .ADllIlESS
<br />
<br />Stevens
<br />
<br />Lucille
<br />
<br />Thompson
<br />
<br />5 6 N. Grace, Grand Island Nebraska 68803
<br />BA~"ER. SII)N~TUIlE & lICE"SE NO #: ~,. Ml:T..ooOf DtSPQSlT'O' 2'b DAlE
<br />
<br />~ R. ~<U(& -(/43 00 Bu".1 o <lo"'ova' 'I'July 1, 2003 ; Westl_i!.W!LMemoria,t Park
<br />[2~a i:I,jNERAL HOME l'4~ME 2'111 CEMETERY OR CRt;;MAt?H"V' lOCATIO"" : IT 0.~ 'tOWN STAlE
<br />
<br />! Livingston-Sondermann F .H. Dc........ Doo:~~_ Grand_~Jan.Q__L..N~lH:as~a
<br />: 22" 'UNERALHOI.IEADORESS ISTREETOIl~FtJ NO CITVQQTO\\N SlATE_ZIP;
<br />I
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<br />.'.-~,~rr~ny o~ C~f~.U.l o~r'; NJI\ME
<br />
<br />Road, Grand Island, Nebraska 68893-4050
<br />C IENTERONLV ONE CAuSE PER ~INE Fan ". 'bi ANDICIi
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<br />CJ. (\:\CQ),,'2 '_
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<br />DU~ To OR ~S A CONS~OU'NC' ""
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<br />e: ~~THE~ SlGN1FiC"NT C(J~OITlCNS . Cond~IId.f't!i c.()ftIrlbl.,Mq to the <Mam bu1l'\01: r8lal@(l
<br />PAIn
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<br />; 26a II 26b OATE O~ INJURv IA/o. OfJlI Vf J 126t: HOU~ OF IPIlJui;JY
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<br />; n Arc.aeI'W 0 ~"~.r!TI;ned I . I ... '
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<br />1 ~ ~;.e'\:Jt C ~~!t'tQll"lq : 26e INJu~"'~TWORK I ~ P'i.ACEOFINJtJRV.At~{I' f8"'11 511~ lac1Q1'~ 1,26q tOCA!IOt\l -,-.~..- ~r~EE' Ilt:i~-~ril'16-~--~~;;~~
<br />I :; \ DO! offie.l:)jl(ll~ e!c ..SpecJ1y1 "
<br />I L..._ I-IO~I(~._ InV~f1Q"t'('}f'! YM No I
<br />
<br />: 21, :lATE OF DEAT'" ;.., V.. Yu I 1260 ~'T< SIGNED ;;':'''~.'"----'-----T2B" ""t o' OEM'"
<br />
<br />",; l.i-- June 27 f 2003 I ~'ii- I 1.1
<br />t ~ " i 27t1 ~ATE SlGNEO IMo 0., ." : nc TIlliE OF OEAT" I i ~ E; 28< PRONOUNCE[: D,A;) M" 0., v,.---' Ta;;-~"ON(MKll. :.lEAO "1<""
<br />sit!! I I~~~i
<br />H L::l-J~Jne 30 03 I D~.5 ...
<br />
<br />:. ~ I '7d 1 (\ 1M best of rn le~QE.' ~ lime. a,tee.p1aCe due 10 the ~ If 1".1 ~8Eo 01'1 11'1111' b8s~ of e~a~I'lql10n i}'l{t ::Jr :/"I"'.P.~llg8TioI'l ;:1 mv opinion Oealh :)("c~.n'tea
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<br />.. ,"",.1>"'_. o. .. "'. I m" .....no ",,,,,no """'0 1"9 cauS.,,, ".,,,,
<br />
<br />~n..1tur.Mdt~;. -V ~ --L- L!SIQrtaU.l'Qifln'~fltl&l.
<br />I~' DID 'OB~CCO USE CONTRlaUTE 10 ~130' "AS OIlGAN OR TISSUE DONATloNBEEN CONSIDEnED' :;00 W', CONSENT GRANTW'
<br />
<br />! -1--_ ~ VES e::r;;O , --\-.. 0 VES ~ I r-" 0 .ES ~
<br />3~MF- AN~SS OF CE~llF-lEf' !PHYSfCIA~. COROtIIER S PHVSlClAN OR COUNTY ATTORNEY: .. :~~:,r'
<br />
<br />~__.~_.r__ .-.--.~.~...---:;:;I:'~.'l,1 b@o'~e" {Jtt!i~l ,}l"Jt: 11:".lfr'-w-.
<br />
<br />'I PAR~~-:;-\'~O--"- .-~r::Trc'P.i~~._.-"7 i/'JA~ r~ASf REFERRED 1~
<br />PFlEGNANCV IN THE PAST:I MONTHS.... . i EXl\MINER OqCO~Op..~p~'
<br />I iA9E'!,10.~AI \'~t> rl NoE~:....O~.L~~r_~.~ n No ~
<br />: 2Sd DE()CRI8~ I-IOW'N~JR''t' "")C('~iR~f.O
<br />
<br />,..r Dr Ryan
<br />
<br />~lPh'
<br />
<br />32<1 ~fGlstRAR
<br />
<br />_GranJi~nd ,NE 6RR03
<br />~ 32b !')AtEFlLEOB'f'Re.t>15TRAP 'Me o~" .,.,;
<br />
<br />JUl
<br />
<br />2 ?003
<br />
<br />L
<br />
<br />Lots une Hundred 'lwenty (120) and One Hundred Twenty-one (121),
<br />~tJMlt Addition to the City of Grand Island, Hall County, Nebraska.
<br />. YlYnt
<br />
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