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<br />~
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANQHJ!MAN.$ERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAI.f!ECQ8f) oN~ WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT1ffic8~E.i;'rn:jjt~/Cl! IS
<br />
<br />:::::::~:;RY FOR YfTAL RECORDS. Mi~~~J
<br />SEP 2 6 2006 20060984 7 A~!STAN:;~;i::~~~9rkA:
<br />LINCOLN, NEBRASKA HEAi.'tH Af.g)H~NS!iRVlCES
<br />
<br />';:'"::.-'
<br />
<br />SlATE OF NEBRASKA - DEPARTMeNT OF HEALTH
<br />BUREAU I)F VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />
<br />I. oec,,'iiNf':';u(.;;r--
<br />
<br />ARST
<br />
<br />UlOOtE
<br />
<br />lAST
<br />
<br />2 SEX
<br />
<br />95. 9355
<br />, 3 PATIO OF OEATH 1_.0..,. Y_I
<br />August 26. 1995
<br />
<br />Jessie
<br />. .. OTYUC>ST.TEOFfW:tfH f"n<<nU.SA,~C!OufWyJ
<br />
<br />Lee Count . Virginia ~1
<br />- > socw. Sf(,'-'ImV I<<JUIlffl
<br />
<br />Rex
<br />
<br />= 227-22-3554
<br />- .. TAtelnY: -..
<br />
<br />
<br />Collier
<br />
<br />Male
<br />
<br />Nebraska
<br />
<br />
<br />
<br />;;N~~ I 'iEAA ~OER 1 DAY
<br />Sb ...os I Oit.ys !)c;. HClURS w.lS
<br />I :
<br />1IO ....ACE OF OEA TH
<br />
<br />~SPlTA!: l;J-
<br />
<br />=L \ 8:~
<br />
<br />lIll ~ ClTYlIUtTS I lie OO:JNTY OF DEATH
<br />
<br />V.. []j No D I Doug 1 as
<br />9c CITV. TOWN OR lQCATION lld. $TflEET A"PNUUlIEfl
<br />
<br />6. DATE Of BtilT... ,~. D"_It. Y'NWI
<br />
<br />December 12. 1923
<br />
<br />OT",!!"
<br />
<br />DN""""l-
<br />o -.-c.
<br />
<br />D 0\Il0> '$p<<<,'
<br />
<br />/11""'.--.._--.._
<br />
<br />Clarkson Hospital
<br />.. ~OilLCCATIONOfOE.\TH
<br />
<br />Omaha
<br />
<br />.. flf$ClfNCf. SUTE
<br />
<br />68801
<br />
<br /><lo IN5lIIEClTY UWTS
<br />...lXl 'io 0
<br />
<br />rIl><Iud/IIgZ~~1
<br />
<br />10. RACf..ft9-.....lIIIck 4rTwntmRSllll1 11. ANCESTRYle.g ~,Me.l:ltan.Gerrnan,etcl
<br />*.IISI>oeIrI Wh 1. te I ISQo.;...1 A . \) b
<br />mer1can
<br />'... U50Ool. OCCUPATION 1~_ot_donetUlng""'"'
<br />ot_......_~_, L""
<br />CIvil En ineer ~~~
<br />'6 F~TtiEil._ FIRST ....POLE
<br />
<br />13 _OfSl'OUSE ,.__-_
<br />
<br />17 YOTHEfl
<br />
<br />LaVerna Beck
<br />-~
<br />4C0109o .,..",,-,
<br />
<br />Ol'C.llLE MAIDEN ~
<br />
<br />Construction
<br />
<br />LAST
<br />
<br />
<br />I
<br />AflST
<br />
<br />!som M. Co 11 ; er Myrt 1 e
<br />18 'W~s DECEASED EVEfl It< u.S. _0 FOflCES? . WW I I
<br />I lYV-es-' d~f9=19441Q"4:"26-1946 LaVerna Collier
<br />,QI) '''FClAlIWiIT MAIUNG AIlOAESS ISTflEET OR R.F 0 NO. C::V OR TOWN. STATE. 2lPl
<br />
<br />Woodard
<br />
<br />
<br />Grand Island. NE 68801
<br />
<br />,(- 2~=~D~~ ,2~~;0/1995 (~~:~T~flV~;:AT~:m:ery
<br />
<br />21lJ CEMfTEf:lv OR CRt:MAfQRv LOC.UIClN CITV OR T~ STArE
<br />
<br />Apfel-Butler-Geddes F. H. D~ D~ SC('l~;a. Nebraska
<br />22b FUNEAIII. HOMt AllQflESS (STREET OIl R.F.O. NO CITY OIl-TOWN. STATE. ZIPl
<br />
<br />I 1123 West Second Street Grand Island. NE 68801-5899
<br />~P~~7lJ~USE , 6t~;:;:;;' 7tJ~s FOfl.., .., AND 1<"
<br />
<br />DuE 1O.0fl1\5~OF
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<br />~atDllwMw1~ anc;1dea*t1
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<br />:a MAH~
<br />
<br />I ~\!aI:~~~~
<br />
<br />lbl
<br />OUE TO. OR All A CONSEQUENCE OF
<br />
<br />
<br />I ~_~-NIF~' !lIT~' ~",..._tlUI""'''lMtd PARTIO'FFEU,lLtW'STH[!'EA i" AUTQt>$\'
<br />P~RT _GNA~' iN THE PAST J """'THS-;"'" I
<br />Ii [AQe~IO.:)4. Ye:!. ~~"es
<br />2llo ' '200 DA To OF INJUIIY IIAD """ y, J I 2lI< ><D'''' OF ...,..... 12'l<l \isc_ ><OW IIICMlY OCCuAflEO
<br />
<br />o A<:.-. 0 -..... ! I ..
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<br />o Suooodo 0 ~ I ?So """""VATWOIlK J'~ ~~'IlYi=,...m""'l~ lClCATION S1!'Ef'C-"'RFOIIIC
<br />
<br />0-... - i v..O""O
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<br />27.. OATEOFOb\TH I~'--- _ ,- ... DA'ESOGHeD IIfr ,... '" ,... TlUEOFOEATH
<br />
<br />n '27bDA~P I""W:t e2(,'rL~~~TH ~Ii<r~ 2k-PRONooJIoY"...wo;;-.~,......".--t2M~H;Ql;.OO"'" ..
<br />-~~~I~~~(11'l5! 1Z.:~f, ~laiP _~_.~______I . ..
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<br />l~ os.>.ccC'J& - . TISSU[,;ONATION-=rCONSIllEflIio> IJO'WAS~!lTGIWITm'
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