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<br />~f /3 1l!!J2, z g crqo.v if #W /I}) J/, <br /> <br />WHEN THIS COpy CARRIES THE RAISED SEAL OF nfilBRASKA STA1E:8a <br />DEPARTMENT OF HEALTH. IT CERTIFIES THE BELOW TO BE ~.TJlU.ECp'~!<,:l 0 2 5 0 1 <br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPAR!MiNT 'OF~,HEALTH, <br />BUREAU OF VITAL STATISTICS. WHICH IS THE LEGAL DEPQsiTORy'FO,a;:/;; <br />;,' ,"'~. -' .' " ;", , .. <br /> <br /> <br />:::~O~:::CE JJ...",;~~,;\'/' <br />/j1~ ;C:.'. :.,-~- . 'j ~~~J : ''CC <br />MAY ,1 3 81) . STANLEY S ,('COO~D:;,riI!' )()'llOR>' <br />~ ... ',",,",. 'l',-" '. ~ I' ':, <br /> <br />LINCOLN. NEBRASKA BUREAU OF 'lIT~~ '~~1trSNCfS'. <br /> <br />STATE Of NEUASU-DEPARTIHNT OF HEALTH <br />IUREAU Df VITAL SIAn sTIes <br />CERTIFICATE OF DEATH <br /> <br />86 099,,'7 <br /> <br /> <br />DATE Of DEATH (Mo, ""y. y, , <br /> <br />) Sept. 4, 1986 <br />U_II I DAY OAlf Of iIIIITH t_., 0.,., Fd <br /> <br />1920 <br /> <br />2nd St. <br />... <br /> <br />.Forrest G. <br /> <br />WAS DECEASED E\l1I IN U S. AI/lIIED 'OICfS? <br />f.';'. -N (; ..".. I eM "'. gl" .... ..... ..... .t "'.'Iel <br /> <br />au.tAl. C,.IIla';Olt_ .....DYCI. OA <br /> <br />Johnson I Rose <br />IN.OI/IlANT - NAM' - IUAT,ON5H" - lOIA'lING AOOIESS <br /> <br /> <br />~. Scott <br />,I'.f' 01.' 0 Net- an o.lOwN. St&ll.. .l:dl', <br />.t.~'3+:; <br />"Charles G. Avery Rt.1 Box 173 Gordon. tlelSr. <br />, CEMUEtT 01 CIEMolITOIr - N....E I lOCATION CIIYQII YOWN STATI <br /> <br />10< Gordon ~el!!e~~_--L2Od Gordon Nebraska_ <br />'UNUAl HOMI - N....' ANO ..OOIE55 (UlnT 011' D NO. c.n 01_. STAtL P'I ," .~ <, <br />;.r'y';;'~, <br />Nebr. <br /> <br />387 Gordon. <br />'HOUIOf DlATM <br /> <br />. <br />'~.b <br />lHONOuNcfD DlADr_1 <br /> <br />II. <br /> <br />0.... ......04 _ .__.. ..___.. <br />... h.., __.-_.... ..........- <br /> <br />~.. ,5'1_ _ TdIe!. <br /> <br />A"OINtyllrr~." ''''''I <br /> <br />IT.nOllI.6... <br /> <br />c.n ~ _ IT"" <br />