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<br />WHEN THIS COPY CARRJES THE RAISED SEAL OF THE NEBRASKA HEAL TH~~f!f)'fitYMAN SERVICES
<br />SYSTEM, IT CER17FIES THE BELOW TO BE A TRUE COPY OF THE ORIGIJJ#i€1f~"'tJ!1-FILE ~/TH'
<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL Sf!AT~~S.SIt~N;'~H IS
<br />
<br />:TE~:~=TORYFORVTTAlRE~ (~;1~
<br />APR 2 4 2003 20 0 6 0 8 5 0 3 ~;',isSIS~J.Nt:&W ;eJJ:=
<br />LINCOLN, NEBRASKA HEAL TH ~~If'-HU~!f/f!flV!P.Ii;J:JJSTEM
<br />.-._~~ -,--:;''''-',~-~'::~5~,.-~~
<br />-. - .-~'- .,.', '. '=..:-:=- '"";-
<br />:,7.~, ,,~,':''' ~_~...:'.
<br />.'7. :~._,,'~..,;....~~r_
<br />
<br />STATE OF NEIRASKA-DEPARTMENT OF HEALTtr""c
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />
<br />7S
<br />
<br />08968
<br />
<br />...
<br />
<br />
<br />I.
<br />lACE (..g., Whil., Block, A".'KO" OIIIGIN(DESCENT (..g., 1I"1;,,n, M..it"n,
<br />Indian. ....) (SpH;lt) . G.'.....n, .k.) I~p..i/,) . :'
<br />4.... . Wh.A ..t.e. (elUna.n.
<br />CITY ANDSfln OF "ITH (If n,,1 in U.S.A., CITIZEN OF WHATCOUNTIY
<br />na... '''unl,,)
<br />8 (jood ki..ve--t,
<br />SOCIAL SECUIITY NUMBEI
<br />
<br />lJill..A..-am.
<br />
<br />lIt. e..dA.A...cJ:..
<br />
<br />DECEDENT NAAlf
<br />
<br />fllST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />1910
<br />
<br />~
<br />
<br />--
<br />~
<br />
<br />-
<br />
<br />l It~. (~Ju:J..nd :]/.l.Land
<br />RESIDENCE - STATE COUNTY
<br />
<br />~ JS"nei.JM/.lk..a 15b. /iaU
<br />=' fATifcil:"'WMr- rill i
<br />
<br />~ 16. /;)..L.Ll..Wnt 1.
<br />
<br />WAS DECEASED ~'VER IN U.S. AIMED ForCES?
<br />('re,. no. Or un~) I (If ,...... giVlt Wlgr C1.,.d dat.. ot ...'~i~.)
<br />
<br />II. no I
<br />
<br />BURIAL, C,...."I;"n, R....".al DA
<br />
<br />( un!:...)
<br />
<br />c.wo.J...cLt
<br />
<br />($THfT 011 U.D. NO.. CITY 011 TOW"'. $TAlE. ZIP)
<br />
<br />r.,../.. r-:-; 83
<br />/if(;.AJ/UUJ J.:....:.., 0 C '
<br />CITY 01 TOWN STATE
<br />
<br />:zG..:. ~;ood UVVL
<br />($TaEEl Qtt I.F.D. NO.. CITY OlIlOW". ~T"'TE, ZI')
<br />
<br />fL eJ.YW--d m
<br />
<br />wood IU..U'e/L
<br />
<br />IZeh!lJ.14W 68(~8
<br />
<br />""d dv. ;:00 tt:;. 0.. "-_ basia of ..CjI_ina1ian and/M i".....tigotiOfll. i" ., Opiltj,on Math K(:lJrr..d: Of
<br />_, ~ k.Il- A"~ i I the fi... ... o"d place and d". to .... co,,""1) ito,",.
<br />
<br />
<br />lQ l~o I ~~t~i~af." .0<1 T,H.) II-
<br />.~ ~:z:~ IMe a" ,
<br />:: -uf!i I flJ f....~
<br />- r' m. I. 17.79 .- ,M ui~= 24b.
<br />= J1 DATE OF DEATH (Mo.. Do,. Vr.) J~O PRONOUNCED DEAD
<br />; '!i I. 1S'."1q ~8~ IMa., Da" Y,.)
<br />.. 23d. 24 .
<br />;>;lAME AND ADORE S Of CERTIFlr8~FIS'~' ~!f.li\f.t!f.SICIAN OR COUNTY ATTORNEY) (Typ.., P,;nl)
<br />
<br />15. e:.:u WEST 0"/15'0111
<br />REGISTlAR
<br />Q:l1
<br />260. ($;8."..,.)11-
<br />. IMMEDIATE CAUSE (ENTEI/ ONlY ONE C"U~OR'j;,la) 11>), AND c<))
<br />PART C' '_". .
<br />:'" o~srlfJt# ~
<br />DUE TO, OR AS A CONSEQUENCE 6F, A.luholl.
<br />
<br />(b) CoIUN ~JiLl.lll"J =-~~
<br />DUE TO, 01 AS ... CONSEQUENCE OF, -
<br />
<br />
<br />24<.
<br />PRONOUNCED DEAD IHaud
<br />
<br />M
<br />
<br />124.
<br />
<br />M
<br />
<br />
<br />~~
<br />
<br />OA~IVED IY REGISTRAR 1M... Do" y, }
<br />
<br />126~t7t[d ,X'? /979
<br />
<br />- j : 'n"NOl b~ .... ollld ~.
<br />
<br />v : I '/CIIUIL-
<br />~ fr~~:;-;';';; ~~
<br />
<br />. 1""....-01 b.......... 0ftMf o~ 0.0*
<br />
<br />J
<br />
<br />.
<br />
<br />_ (C~
<br />'AJeT OTHE. ""SiG.".i,itiNt caNomONS ~ CenJiticn.. eontribut.nv fa ~~th but fI~t ,..Ioteod
<br />
<br />II ~
<br />
<br />30...
<br />INJun ..., woa:
<br />(Sp4Ki't 'elli 0,. NoJ
<br />
<br />
<br />D...n Of INJU.'IIolo.. Do,. y,.!
<br />
<br />PAIT Ill. IF FfMA.IE. W"'$ ''''llE ... ...UTOP$T
<br />'UGN...NCY I'" THE 'AST3 MO"'THS? IS_,I, '" ... "'0)
<br />
<br />Y.. C "'0 [J 28.)le>
<br />
<br />DUClIlll'HOW ''''JU.' OCCUUlD
<br />
<br />
<br />;;
<br />
<br />3Ob.
<br />
<br />3Od.
<br />
<br />~TIEU O. ..' D. No.
<br />
<br />CITY 011 TOWN s,...n
<br />
<br />:JOe.
<br />
<br />i3011.
<br />
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