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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NED�'A ATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW., -Ti?.. ' .1�%T'E COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STAB kPAFTIUNT` QF,HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE L2` D$'PaSIT*POR
<br />f :y
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />900702189
<br />AUG 019$5 STANLEle - 'rQQMEfi�;°�kRECTOR
<br />tt11 `'
<br />LINCOLN, NEBRASKA BUREAU Q�,�iT STATISTICS
<br />200702500
<br />+O '
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />Vcicucnt -nAME FIRST MIDDLE LAST
<br />X
<br />DATE OF DEATH (Mo., Day, Yr.)
<br />1_ RAY EDWARD REZAC
<br />Zlale
<br />3. August 9, 1985
<br />M
<br />T
<br />Indian, etc.) (Specify) German, etc)(Specify) 0 (yq,1 MOS- DAYS HOURS
<br />Whine s. American � 71 bb. �. Au st 17, 1913
<br />CITY AND $TATE OF BIRTH (H not in U.S.A., CITIZEN OF WHAT COUNTRY MARRIED, NEVER MARRIED, NAME OF SPOUSE (if wife, give moidrn name)
<br />Rome country) WIDOWED, DIVORCED (,Specify)
<br />19,
<br />ME
<br />Z
<br />M tm
<br />n u)
<br />c n
<br />0
<br />ry
<br />oI earl ing lit*, ere" if retired)
<br />n
<br />,_.,
<br />12.505 -09-- 0
<br />13aGrounds Supervisor
<br />,14a.
<br />Douglas
<br />CITY, TOWN OR LOCATION OF DEATH
<br />INSIDE CITY LIMITS
<br />HOSPITAL OR OTHER INSTITUTION- Nome (if not in either,
<br />IF HOSP. OR INST. Indicot. DOA,
<br />14b.Omaha, Nebraska
<br />-4
<br />` ^
<br />M r,
<br />C:D
<br />,4dBisho
<br />N �Rr
<br />r
<br />°
<br />CITY, TOWN OR LOCATION
<br />F-�
<br />INSIDE CITY LIMITS
<br />CO
<br />CD
<br />)sb. Hall
<br />I Island
<br />)5d. 1403 W. 3rd. St.
<br />(Sprci fy Yai ar No)
<br />Is..17es
<br />A HER -NAME FIRST MIDDLE LAST
<br />MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />16. Joseph NMI Rezac
<br />1 17. Sophia NMI Mal
<br />WAS DECEASED
<br />(Y.., no. or unq
<br />co
<br />_
<br />INFORMANT- NAME - RELATIONSHIP - MAILING ADDRESS (STREET OR R.F.D. NO., CITY OleeftTATE. ZIP)
<br />r..R. =
<br />yet. a vw ar and dot.. pt .er -0
<br />NJR
<br />Cf)
<br />Q
<br />BURIAL, Cremation, ernoral
<br />Frac. Lot One (1) in tact, BIOCkL
<br />and its complement,ractI ona
<br />-Te (10()I�ernoh arid,
<br />ofne 1 in vac Iona
<br />Declken's
<br />ock�
<br />Ad
<br />201AU 32 1985
<br />2D.Westlawn Mmorial E=k
<br />Four (4), of Spaulding and Gregg's Addition, Both Being
<br />Addition`'
<br />_
<br />FUNERAL HOME -NAME AND ADDRESS (STREET OR R.F.O. NO.. CITY OR TOWN, STATE, ZIP) 68801
<br />al 4-°
<br />22LJvingsto nann,50 W. Koenig,Grand Island, Ne.
<br />to the City of Grand Island,
<br />Nebraska, as surveyed,
<br />Platted
<br />and
<br />HOUR OF DEATH
<br />recorded rerecorded to
<br />correct legal
<br />y
<br />g
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NED�'A ATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW., -Ti?.. ' .1�%T'E COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STAB kPAFTIUNT` QF,HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE L2` D$'PaSIT*POR
<br />f :y
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />900702189
<br />AUG 019$5 STANLEle - 'rQQMEfi�;°�kRECTOR
<br />tt11 `'
<br />LINCOLN, NEBRASKA BUREAU Q�,�iT STATISTICS
<br />200702500
<br />+O '
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />Vcicucnt -nAME FIRST MIDDLE LAST
<br />X
<br />DATE OF DEATH (Mo., Day, Yr.)
<br />1_ RAY EDWARD REZAC
<br />Zlale
<br />3. August 9, 1985
<br />RACE - (e.q., White, Block, American ORIGIN /DESCENT(e.g ., Italian, Mr.ican, AGE- L..tRinkda, UNDER 1 YEAR UNDE"..7. DATE OF BIRTH (Mo,. Day, Yr.)
<br />Indian, etc.) (Specify) German, etc)(Specify) 0 (yq,1 MOS- DAYS HOURS
<br />Whine s. American � 71 bb. �. Au st 17, 1913
<br />CITY AND $TATE OF BIRTH (H not in U.S.A., CITIZEN OF WHAT COUNTRY MARRIED, NEVER MARRIED, NAME OF SPOUSE (if wife, give moidrn name)
<br />Rome country) WIDOWED, DIVORCED (,Specify)
<br />19,
<br />B. Brainard Nebraska U.S.A. 1D. Married , H do
<br />SOCIAL SECURITY NUMBER
<br />USUAL OCCUPATION (Give kind of work done during mast
<br />KI D OF BI'%INrSS OP'y ^_ ISTRr
<br />COUNTY OF DEATH
<br />oI earl ing lit*, ere" if retired)
<br />�o nhusker Army
<br />12.505 -09-- 0
<br />13aGrounds Supervisor
<br />,14a.
<br />Douglas
<br />CITY, TOWN OR LOCATION OF DEATH
<br />INSIDE CITY LIMITS
<br />HOSPITAL OR OTHER INSTITUTION- Nome (if not in either,
<br />IF HOSP. OR INST. Indicot. DOA,
<br />14b.Omaha, Nebraska
<br />(Specify Ye. or Na)
<br />girt Fheet end aumhrrl
<br />Clarkson Hos ital
<br />Oetpor;.»t/Enwr. Rm., 1 »pad. »r (Sp.rify)
<br />,k7es
<br />,4dBisho
<br />14.. Inpatient
<br />RESIDENCE -STATE
<br />COUNTY
<br />CITY, TOWN OR LOCATION
<br />STREET AND NUMBER
<br />INSIDE CITY LIMITS
<br />is.- Nebraska
<br />)sb. Hall
<br />I Island
<br />)5d. 1403 W. 3rd. St.
<br />(Sprci fy Yai ar No)
<br />Is..17es
<br />A HER -NAME FIRST MIDDLE LAST
<br />MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />16. Joseph NMI Rezac
<br />1 17. Sophia NMI Mal
<br />WAS DECEASED
<br />(Y.., no. or unq
<br />EVER IN U.S. ARMED FORCE57
<br />111
<br />_
<br />INFORMANT- NAME - RELATIONSHIP - MAILING ADDRESS (STREET OR R.F.D. NO., CITY OleeftTATE. ZIP)
<br />No
<br />yet. a vw ar and dot.. pt .er -0
<br />NJR
<br />)B.
<br />19.An eline Rezac -- wife -140 W. rd. St. Grana Island TIQ
<br />BURIAL, Cremation, ernoral
<br />PAT
<br />CEMETERY OR CREMATORY -NAME
<br />LOCATION CITY OR TOWN STATE
<br />200. Buria
<br />201AU 32 1985
<br />2D.Westlawn Mmorial E=k
<br />20d. Gran
<br />EMBALMER- GN TU A LICENSE N .425 ' -
<br />_
<br />FUNERAL HOME -NAME AND ADDRESS (STREET OR R.F.O. NO.. CITY OR TOWN, STATE, ZIP) 68801
<br />al 4-°
<br />22LJvingsto nann,50 W. Koenig,Grand Island, Ne.
<br />DATE OF DEATH (Mo -/�oy,
<br />DATE SIGNED (Mo- Day, Yr,)
<br />HOUR OF DEATH
<br />y
<br />g
<br />23a. �'�
<br />24a.
<br />24b. M
<br />ATE 1 NEDY. /1116.,Da�r,Yr.)
<br />(E�
<br />HOUR DEAT*
<br />PRONOUNCED DEAD
<br />,
<br />(Mo., Day, Yr
<br />PRONOUNCED DFAD(Hour)
<br />y
<br />S
<br />'+
<br />23b. / C�
<br />2 r ` \ M
<br />-)
<br />24c.
<br />4
<br />a
<br />0
<br />e V
<br />To rM bets of WV kno.+l pe, death pc.u...p p) r ) •, h a e. on doe ro tM
<br />.total. /
<br />.
<br />On rh e boom of ar.aminaNen and /or i.. hgatian, m y apinie deoth ac.u...d at
<br />ft.. lime, doer and and du. ro the eauW.l crotrd.
<br />,f
<br />l• C
<br />OOOir
<br />~u
<br />pla..
<br />yr�
<br />2 d Titfr,
<br />246. (Sip »are.. and Tiff.)
<br />NAME AND ADDRESS OF CERTIFIER rHYStClAN, COROMWS PHYS AN OR COUNTY ATTORNEY) (Type or Print) E.C. schater, .
<br />650 North Tower Doctors uild'ng Omaha, Nebraska 68131
<br />is.
<br />REGISTRAR
<br />DATE RECEIVED BY REGISTRAR (Mo., Day, Yr.)
<br />■ '
<br />AUG 2 6 1985
<br />260. (si, »atom.,
<br />266.
<br />2r IMMEDIATE E (ENTER ONLY ONE CAUSE PER LINE FO a), (b), AND (c)) Inanal bet r..» anm end dead
<br />I
<br />DUE TO, O // nprol b.tw. ewr o »d d.oM
<br />" �^ !4•U`t!i?
<br />(a, .�` �- U : L "/u.a�.�. .Y k: -ct� ..f ,G�till.Al��,C ifJ �.t� -G�
<br />DUE TO, OR AS ONS E E O : Inrr^el betr,e.n an..t end death
<br />PART OTHER siGmiffic-AWT CONDITIONS-- C- ditiam evnniburny b "dwrh bur rot rdar.d PART Ill. IF FEMALE, WAS THERE A AOPSY WAS CASE REFERRED TO MEDICAL
<br />11 PREGNANCY IN THE PAST 7 MONTNS9 .if y . rjr Ne) EXAMINER OR CORONER
<br />_ Yet ❑ N6 ❑ i (Specify Y.. .r N.)
<br />}
<br />ACCIDENT, SUICIDE, HOMICIDE. UNpli .. I DATE Of INJURY (M;.. Doy, Y,.- , HOUR OF tWURy DESCRIBE HOW INJURY OCCURRED
<br />O• PENDING INVESTIGATION. (Sprailyl
<br />30a. 30b, 30c,- M 30d.
<br />INJURY AT WORK w
<br />(Specify Ye. w No)
<br />PLACE OF INJURY- At home, I—..t.eer. to.". "-" �
<br />office b.Hdirtp, N.. (Specify)
<br />130%1.
<br />_
<br />LOCATION STREET OR R.F.D. No. CITY OR TOWN STATE
<br />lh�306. _. -- .
<br />30F. _� -- ....w. _, -
<br />
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