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<br />Recorders Memo: The West Half(W Yz) of the Southerly Thirty-Eight (38) Feet of Lot Two (2), and the West
<br />Half(WYz)ofLot One (1),~lock Fourteen (14), in West Park Addition, to the City of Grand Island, Hall
<br />County, Nebraska
<br />
<br />DeCfA!.\'D n_"_
<br />
<br />STATE Of' NEHRASKA~DEPARTMENT Of' HEALTH
<br />
<br />1/)D7 (J JH 8 CER;~;I~~~V~lu~~al~I~~ TH
<br />
<br />~'"
<br />
<br />
<br />! (' ')
<br />
<br />,t..u flU' Hl,lidU
<br />
<br />"IUT
<br />
<br />MIDOU
<br />
<br />\"SI
<br />
<br />DATE Of DEATH (MONTH, 0"'1', "/'EA.. I
<br />
<br />JAIXEN
<br />
<br />18-21-77
<br />0" COUNTY OF DEATH
<br />
<br />RACE Wt1ITf, Nfcao. ",~U,(A,M INDIAN,
<br />UC. l S'I!C In I
<br />~ Hhite
<br />
<br />CITY, TOWN, OR lOCATION-OF DEATH
<br />
<br />I, 6 6-3-1931 /, Hall
<br />HOSPITAL OR OTHER INSTITUTION-NAME (If NOT IN flTl'lfll, GIVl STlfft "'ND NUMlU. I
<br />
<br />I~ Grand Island I, Yes
<br />
<br />STAn Of BIRTHIIf "OT '" U.. A.. "AM' CITIZEN Of WHAT -COUNTIlY--"".'
<br />COUN I'''' ,
<br />
<br />Id Lutheran Hos
<br />/oIARRlfD, NEVER MARRIED,
<br />WIDOWED, DIVORCfD I "w" J
<br />,U.S.A. 10 Harried
<br />USUAL OCCUP...TtON..;'a'I'~f"~.I~'o-o, wou DOH;~~.';~"G ,la\OS10f
<br />WOUIHG lift, [vf:1'-oI I~ UTlIUD I
<br />\Jelder
<br />
<br />
<br />SURVIVlt.ib sPOUSE"; 1~.'~'~~.i:~..o'~f"~~.'ib~M M"Mf)
<br />
<br />. Heb raska
<br />SOCiAl-skURITY NUMi.i:-~-
<br />
<br />II Romana E. Tennus Jaixen
<br />..---.. - -.... --..-.--.- - .._.,.._'------'---_.--_..._.._'--~--'-,.
<br />KIND Of BUSINESS OR INDUS TRY
<br />
<br />llo
<br />
<br />l\"
<br />It, _...
<br />
<br />11 505-28-0044
<br />RESIDENCE - STATE
<br />
<br />14.. Neb raska
<br />
<br />fATHER-NAME
<br />
<br />110
<br />
<br />Ilb Hachiner dew lIQJJa!l9L
<br />INSIDf 'In' ~IMIU STREET AND NUMBER
<br />r $.PlelH 'Y'B OR NO)
<br />I~d Yes
<br />
<br />MOTHER-MAIDEN NAME
<br />
<br />COUNTY
<br />
<br />CITY, TOWN, OR lOCATION
<br />1.,Grand Island
<br />
<br />w.
<br />
<br />10th
<br />
<br />
<br />Hall
<br />
<br />I~b
<br />
<br />flU'
<br />
<br />MIDDLf
<br />
<br />l,,~1
<br />
<br />'IUT
<br />
<br />MIDDlf
<br />
<br />l..,5.T
<br />
<br />Gehanl
<br />
<br />Jaixen
<br />
<br />Erruna
<br />
<br />llanke
<br />
<br />1\ b
<br />INfORMANT - NAME - RElATIONSHIP-- MAiliNG ADDRESS
<br />
<br />II, Hrs. l\om.arta J aixen, Hi fe, 2710 H.
<br />
<br />1~'n:Hf O. _.'.0. NO" (ITY oI6cgSd'tU' W'~
<br />
<br />
<br />10th, Grand Island, HE
<br />
<br />A" OJl:IM,6,T IN .VAl
<br />UfW(fN Op..j$!f AND OlAf",
<br />
<br />PART I
<br />II
<br />
<br />16 WAS oeceASED EVER IN U,S. ARMED fORCES?
<br />
<br />(Y.a,r., ~~~ 9f Uri~liOwn) .!.If y~,ti....e w~r I;Ind1QIOiQj '''';Y'Cj.('1
<br />le~1 6-1 -40, - 4-~L
<br />
<br />C;:OHDI110N~, If A....Y.
<br />WHICH C.....f IIIIU '0
<br />IMMtOl.U' CAUU 101
<br />,TAnNe Hit UNOU~
<br />l't'IMG 'AvH ~"U
<br />
<br />DfATH WAS CAUSfD BY,
<br />
<br />[ENTER ONt Y ONE CAUSE PER liNE fOR (a), (b), AND ((II
<br />
<br />IMMfOI"n c.J>,~,'
<br />
<br />
<br />&l, MVVJ
<br />3~
<br />
<br />(QI
<br />~ " CONSlQufN(f o~
<br />/'
<br />
<br />Ib) !:)D~V
<br />Out '0, O.~N~fQUfN<;f Of'
<br />
<br />(e)
<br />
<br />'"U II. OTHER SIGNifiCANT CONDITIONS, CONDITIONS CONTlIBUTlNG TO DfATH BUT NOT .ElAnD
<br />TO CAUSf GIvEN IN 'AU 1(0)
<br />
<br />
<br />IF YES wUf: 'IHD'I'IGS (ON.
<br />SIc/UfO IN OI:HI.....INIHC CAI,IU
<br />0' DfAB1
<br />I'"
<br />HOW INJURY OCCURRED i fNTU NAfvltf Of INJIJlv IN P.a.1H I 011 PAIH II, IUM 1'1
<br />
<br />ACCIOENT, SUIClDf, HOMICIDE, DATE f INJURY '''O''TH. DAY, YfH I HOUR
<br />OR UNDETERMINED I "WOy J
<br />~ ~.
<br />INJURY AT WORK lOCATION
<br />'VfCHY YU 01 NO I
<br />
<br />10,
<br />
<br />M. lOll '
<br />($1ItHf 01 lI,f.D. NO., CITY 0111 TOWN. Soh,Tt I
<br />
<br />
<br />109
<br />
<br />CERTlfIC.4TION- .....OHfl'1 OA't "tAli MON~~ O.&."
<br />'HHI~I:::""D'D TH' II f' ItA 'JeTO' ,." J
<br />1la., DfCUSfD f.O..... l.i . -, J 71b.' ~
<br />CfinIFICATlON-MfDICAl eXAMINER OR CORONER, 0" TH' ..... 0' THI
<br />fJAMINAfIO,,", Of THf IOOY ANOIOI fMt IN....U"G"'ION, I,... /11\'9' O'INION,
<br />OfAfM OCCUUfD ON nit DAft ANO DUll: TO fHi C"'U~fISI HUfD
<br />11.
<br />CERTlFIER- NAME lTY;tO.". iit~~~
<br />
<br />ll. VI.L. Fmvles H.D.
<br />MAIliNG ADDRfSS- CERfljifR=--~==--
<br />lld
<br />BURIAl, CRf/olATlON, REMOVAL
<br />( s,"C"y )
<br />
<br />
<br />14, Burial l~b Hes tla\vt1 Hemorial Park Grand Island Nebraska
<br />OATE - 'Io'O~f", 0.', yu., FUNERAL HOME-N~Mf AND ADDRESS I STU" O. III.'.D. NO. CITY 01 TOWN, STAU, ZI' I
<br />1<<1 8-2 - 7 lIo\)fel-Butler-Geddes FunerallIome Grand Island, NE
<br />
<br />..)~:A~r-S/G!):r:'j1j:~S.fE./.O(!. ~ 'II' Jrj ::.GISTRAR-SIGN7Rtl~.~,."] 7d V ,i/
<br />. ,,)1-/'&7, L-ijf1 ~ J j yf/C7 Jf11tl.(4""f.1c
<br />
<br />
<br />~. :~.... ~.J..17';":~'<'4,J :~r, ' "
<br />J.;;;'-:.~Ht'Nft~;COPY CARRIES THE RAISED
<br />,~':'.ST~A!t&,'i)at'ARTMENT OF HEALTH, IT CERTIFIES
<br />A i''i'{UE, :,cl>P OF AN ORIGINAL RECORD ON FILE WITH THE
<br />IlEPAltTME~~ OF HEALTH, BUREAU OF VITAL STATISTICS,
<br />" IS'-:r,HE/ iiKGAL DEPOSITORY FOR VITAL RECORDS.
<br />"'.'i ''''~":'.''....y-',':',,,~''\~
<br />,;:"'~':'''~~ .', ~,
<br />" / i C'.\"f \\;
<br />'DI~i&rOR'OF VITAL
<br />LINCOLN, NEBRASKA
<br />
<br />AT hH "LACf, ON ''''I:
<br />O.a.H, "NO, '-0 nil: US'
<br />0' M" I(""OW~fDGf, OUf
<br />TO H'It (AVU(s'J SU,HD
<br />
<br />72 7 II.
<br />
<br />CITY Ot 'OWN
<br />
<br />68801
<br />68801
<br />
<br />DAn .fCII!:IVl"O tv LOCAL ItfCISU....
<br />
<br />1.bUh_? ;l. t /1777
<br />
<br />i'"
<br />
<br />SEAL OF THE NEBRASKA
<br />THE ABOVE TO BE
<br />STATE
<br />WHICH
<br />
<br />..
<br />.
<br />.
<br />.
<br />rI"~ "
<br />'<~.' ..
<br />
<br />dA.~ ~4.J
<br />STATISTICS AND ASSISTANT STATE REGISTRAR
<br />Issued August 29, 1977
<br />
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