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<br />200700473
<br />
<br />HA.S-<l2'76
<br />REV, JULY 1992
<br />
<br />TVPEIPll/NT
<br />I"
<br />.Jl...\C"'I~
<br />FOR
<br />INST1lUCTlONs.
<br />~tEllA.NDBOOIt
<br />LOCAL FILE NUMllIUl
<br />
<br />,. OATH. or DE.A.TH (MMffl. ~. r.~rJ
<br />
<br />ST ATE OF SOUTH DAKOTA
<br />IlEPAltTMItNT 01' JDI.AL TB
<br />CERTIFICATE OF nEA TB
<br />
<br />1,40 STATEFILENUMDEIl.
<br />
<br />D03030
<br />
<br />~")
<br />
<br />
<br />1. D~CC:OJtN'l'" NAME (F,rn J4fddl..t. LlJItJ
<br />
<br />Februar
<br />
<br />7 2003
<br />
<br />Max
<br />
<br />Donald
<br />
<br />7. 81RTRPL.A.et: {C1tJ and $'1411111' For'Ii,1
<br />c.....,.,
<br />
<br />4. SOCI~L 8EC(JRItTV,Nt1MIIGa tit. AOa..Lut "I'IbMt
<br />..Jr..,,,.} " _,u.
<br />
<br />",--,'
<br />
<br />Grand Island NE
<br />
<br />
<br />506-28-3542
<br />.,W".Ill<cmeNT,_UOll.5.
<br />AR.M~D JO-.cRS't ,:0' ,.'f.;;;::' " .',
<br />('(~,u'N~)"". .. ye,..s....
<br />'b. F,,-ClLrrt NAMI (lJ"ot 1nII'~UM, "ilt' tr'~.' 11114 nJiJflbm
<br />Tea Steakhouse
<br />
<br />s /; J-
<br />. "...... ~..' ... td. COUNTY OtDEATH
<br />Lincoln
<br />
<br />o
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<br />N
<br />!:'-
<br />o
<br />N-
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<br />Ut. MARJT"l,."TAT\JS~
<br />N."cr~ w.........
<br />Dlvofad. Spu:tfy
<br />Married
<br />
<br />U4.I1'AEET AND MUM'"
<br />
<br />Sales
<br />
<br />u.c. a'!"Y, TOWN.. 01. !.OCA'fION
<br />
<br />Grand Island
<br />,. W.\SIl~ItDENTO"IIISI'ANlCORGlN1
<br />(SpedtJ NQ or y..u J'lIII""" CdY.
<br />='..........-...., CJy.. !HNa
<br />
<br />1416 W. 6th
<br />I" aAClt-AiMfican l.dI.~1
<br />...... -.......
<br />(.,...fflol
<br />
<br />t.
<br />
<br />Nebraska
<br />l~ INSIDE ern'
<br />L.MIT81
<br />(y,..,urN~J Yes
<br />
<br />White
<br />
<br />16. l'IaTHKR.'S NAMJ. (P;rll, AlJMJl. Lmt)
<br />Max J. Tagge
<br />
<br />11. uomllR'8' NAMI!r. (PI17I. M~, AI~ti SwntDlf.J
<br />Olga schoel
<br />
<br />1" ""lUNG ADnlUtM fS'rfJf'unJ N1UJ1blfflf' If~' ~ N.". a" II' 7'~wn. s..,.. zjp~)
<br />1416 W. 6th St., Grand Island, NE 68801
<br />
<br />lla.lNFOIlMAJIIf'T'S NAMe (fwdlPrlIU)
<br />Lorraine Tagge
<br />
<br />19. M~OD OF lJISPOKI"tIOI\II
<br />
<br />19b. puo: o,nl8pOImON (NaN 0/""'''' ~'mIIIIMY. ,,,.rp~J
<br />Grand Island City Cemetery
<br />
<br />lid. Ne.u_MEn?
<br />r.p"",'
<br />
<br />rx Burlal 0 CIOlDlIlillll 0 R.emovallrom S_
<br />O Donation 0 Olhor (Sp,cify)
<br />
<br />lih:. LOCA.'ltO'" (OQl..JuJu)
<br />Grand Island, Nebraska
<br />
<br />jEl '1'.. 0 No
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<br />)
<br />
<br />
<br />APP~I~orvp.1
<br />BoN'''' OUllt Q:D.d oulb
<br />
<br />/llb. LICEHII< MlM.n
<br />(0/,-1
<br />
<br />21. NAMltAND A.PDB.I!:IS 0' F,\CU1'V
<br />Heritage Funeral Home
<br />Sioux- Falls, SD 57108
<br />
<br />130
<br />
<br />\..............-:
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<br />u11. ~&ba~, ,Gr~""'CIIIlIueCldl."'b.~ItO"iIQIlI.f'tbcaloN f1I.,...mdI.~(It""'~atnI"'"
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<br />................l Choking ,on food-meat
<br />
<br />~:f~=~.:=C {... JWE TO (011 AS ^ CONSEQlJENCI 01'),
<br />CliIdCo ltil;l'f UNDEBLYJNG
<br />CAtJSE1(~Or~ Co
<br />ihat ;.iU.Q.Bd.~ I)UIl: 1'0 (oa '" A CONI&QUP1e& 0"1
<br />NM&Un. 'D. ......) L,t\8'f
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<br />~. WJl:IlR ..urO"" FlNllINGIl
<br />aV,uLaUI,Jl PRIOR To
<br />COMPU:'nON OJl'CAUS~
<br />OPDKAftn
<br />o V~ 0 No
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<br />,... WAf AN ,UlTOl'lIY
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<br />
<br />16A, DA~ Of lNJUIlY
<br />(M1lllll1h,1M)', Vnr)
<br />2-7-03
<br />
<br />)&d. UUClIBK wOW INJt!~Y occ~
<br />choked on meat
<br />
<br />2'''. CE.TIn....
<br />(ChoQk _11-.e)
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<br />o CJ:RnnrflilCPHYSlCU.N (PJI,..~htII:t:.rfIh*II~IJ/~"dJ)
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<br />
<br />%l CORONER
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<br />S"%16
<br />j 'cU' 1m
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<br />
<br />De ut Coroner Linooln
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