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<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANDHlIMN'lSERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINA,I;REf'!fJ~qN'F1LE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlST1esS~C_TIf)N-,::Jo/HICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~'. '~.' ~/j/",-}.'j'.~ <,:ce,-\,..
<br />
<br />DATE OF ISSUANCE' .- c,1J._"' .~f't..
<br />:-: ""7. ..:: - .::. :: I", : -:: - .,~
<br />6 2006 .... ,....',.. TANLE'IS. COOPER
<br />nEe 0 2 0 0 7 0 ~ 3 8 9 ..f$$1stANT STATt;l'E..GIBr.,ffAR
<br />LINCOLN. NEBRASKA " HEALTH ANDHy-'~~N};ER-,ijcES
<br />
<br />-- : -: - ..;:'~::-:--
<br />
<br />STATE OF NEBRASKA - PE,AftTMtNt OF HEALTH
<br />8URUUOF V:TAl STA11S'flCS
<br />CERTIFICATE OF DEATH
<br />
<br />96....06710
<br />
<br />UiiAAf . --~-"~-~'~-'-'.'--'~~.;---~~~.~.">'.~Of:-rX~~,~r_"t...---'---~-
<br />Josepla Crick Male i June 13. 1996
<br />~"'()E u~! ~\' UMOEJii" "flAP ._.~M~T'''''''' '1 ~ DAU (lI ~'7~ ~~ 'tN," -------...~..
<br />
<br />____-L~=__,__~ pt:=~'" DoWS :_H00R5 "::=;.__Novc~M' 12, .~?~~_
<br />
<br />HOSPlT.... 00 - O'rlI,k 0...............:
<br />
<br />;-8b-;;lClli.rV~:~ r''''C4~~-..w.Md~J 0 tR~ 0 ~II!
<br />-= Mary LanDing Memorial Hospital 0 'lOA 0 oor... ,$po,
<br />~ ~iOWN<)IlU;>(;"TtONl)fllEATl< ... IN5lOfClTVl....1S T""'c~~---~---
<br />
<br />
<br />!.~" T.;:.;w .~~:~=.:DI ~-;:-;;~:;-;---~~=~Q
<br />
<br />1.0 "'WI1'QA".ACE '-.If")',._, U4..;k AmeflCatI"'an 11 ~eSlj,]YU~;g ..., _..lColt' GtJI'l~.".:1 I? ~ ,.RM.,U f.'l WIOOWEO 1 H NAUEOFSPOuSE. .. .1111 Qr\.9P'1rt1".Mr.IJ,,;t.,
<br />ISpo<.., :', _ I' I!!J 'c'-' [ .
<br />American _~~D ~~~;l ~VOHCED I Ileac M. Blgger
<br />1... USlJ.Alor~UPATI\)fIl 'Gtllelt"'fJot~~tIfJMg~ 14lJ IIltNDOFBUSiNf.SS'NOuS1J:t'V . t~ EDlK;""1O"'f lSDec""~:l~gr"C~)
<br />;; o;;~';'iO..e-;ror '~f.\'? ~rocery Store G::l\ r-e....".._.,O.l, - ..- "'''';'''
<br />
<br />.6 fAT~~_;;mund fAST ~~ ~~ri~~~_~1;~es-'f~;' _=~~'-----~NSU~OIT
<br />
<br />';1 ,.""~ DECEASE;> tvER IN uS __0 FDOlCES' 0210211943-: 190 "'FOIlMANT, ""lOt
<br />IV-ye;""'-) 'Wo'rld-wa'';ii-'''' IUI.~/I94$ i Ilene Crick
<br />-~-_._._-~--~-~--~-~..~~
<br />.., WOIlMANT IlAII.JNOAOOf,rss iSl"Hl<)IlRf" 'j{) C'TV<)IlTOWN STIITE lIP;
<br />
<br />, :'t:'C'Ull:':'" ~ fl'RSl
<br />
<br />Be....rd
<br />
<br />.. crl.".\M)S.AtE.or~rrt .'.nd"U5A "'"'~
<br />
<br />Gn... blaH. Nebnska
<br />
<br />.h socw. SECUIlTrt "'-R
<br />- 501.1....1539
<br />':
<br />
<br />
<br />304 W. 15tb St.. Grand Island. ~ebl'llska 68801
<br />~ ~f - FtQ . -~_._','''m''~'-n:~.i-tiF'fHOOOf=f)I"'PO$l''I(~.-'T'nb~i:i;fi~"_.~.m"_.,~-._-~! 'i1( ce...tfERvORt~R[fJI"'lOR'y N.wE ,-~~
<br />, W'T~FNSE.~ ~~~-l' E!] l'\u>"oAI 0 ......~.. i 06/1 './1996 ____ _.LWfll"lawn Memorial Park Cemetel')
<br />no FUI<l: ~. 1;.0 cE....r~..f(..c"f....'o<<YlOC"K'" CITY OH TOIIVN SlATE
<br />~prel-Butler-Geddes Funeral Home , D.,........, 0 """"""" i (.rand Island, Nebraska
<br />-- -__""__..1..__.___.~~_~_._...L__,_______________~_
<br />2:'l> FUN!:RAl HOME ADDIll'SS ISTREff OR R, 0 "'" cln. '-""'OWN S' ^'~.llP:
<br />
<br />I ~ 112~,::~.~~~nd Grand Island. Neb~~~~~~~:~~ lINf FOR '-, IN ANt'1<11
<br />P.>.R'
<br />_" I ,..mul tiDle system fail ure 1r.lliirat.9~r~_tlah. he~.!:1L_________.
<br />DuE 10,011 AS ~ CONS€OVEIICE 01'
<br />
<br />~al b8twIttJrI onset ana d@dtll
<br />
<br />lnIerlfal betWeen ORiel Qn(J (Sea1l1
<br />
<br />4 hours
<br />
<br />
<br />Ibl S8Dti cemi a
<br />. '---DpS~eMb1rri'ftW'45P'i nary tract 1 nfect 1 on---'~-------~-~--' ----
<br />~c'StaDhanreusJlneumonia '______"~____
<br />
<br />or~E""I StGNlFtCA~r CONDiT S. ~I()t\t. COt1ttlbutlng t!! IhE! death bl,ll ~ 'el"l€'o ~f PART lit IF '-EMAt,.>: ~.s: H[~f. A . ~\JfOPSY
<br />f'~PT PRE<;iNAt.lCv IN THE ?AS t J ~NtHS? I
<br />
<br />__~ 'AQe~_~~!es n illL ~~ II No
<br />~~. 2Gb D"'TEOfI~UAY IMe Pall Yrj Iztic HOllROFI'.uU~V... )"" f!'&1... OfSC~18EHOWI"'JURYOCCURRl!:l'
<br />
<br />[j "'e""''' 0 U_m._ !L.L
<br />
<br />0- 0 - - ~,~,,- ~ :!oF'a_. .",,- -I ,~,~---....=".,~
<br />[J .".,,"'''''' ;""_ V.. 0 No 0 · ......~ ole ,St>e<ity
<br />
<br />----.-- ~--
<br />27. O~TF.1)f ~TH (410 D.Jv ...' J I . 2ft;. DATE SlGf04:D (410 D.b Vt.. I 28b tiME Of; DEATH
<br />
<br />13, 1996 I ,'U' I
<br />
<br />.-~OFOEATH~-~~ !~ ~ ~ 1- 1&... pROt\fOuPfC-=:O DEAD rMa lJ~v Y, I
<br />I .r. -",
<br />~~ 5,
<br />" I2IP" f
<br />I ;! ~ ~ I ~ On tho bFr.ar!o of tJlarrnnal\of'l and G 1JIV(t$~"I. I" my OPIntOn d8atn oc:cutf8d $I
<br />, I -... me tIme difIiII ano DlaCe .lnd ltUl;! 10 tne ea~$l ~
<br />--- IS,' .WT...) '-L ---1:_ s,q........."..:J
<br />~29 DiD TOBACCO USE CONTRIB"TE 30' HAS ORGAN OR TISSUE OO~AT.o.. BEE"'-' ONS<DERE~ 30 b WAS CO/'ISENT GRANTED'
<br />
<br />00 VES 0 ,~, D UNKNOWN D vES ~ ". , D yES IKJ NO
<br />
<br />J1 ~AMEANDACORl;SSOFC'E~~I"~ P.~VSfClANCO~' lERSPHYSlQAWORCOUNt"t'ATfQRNf;V fWf'CW'Ptlf'fJ --
<br />
<br />1 - 2 days
<br />In:$rv~l belween DI158t ii1nd ~
<br />
<br />2 - 3 da s
<br />
<br />
<br />CI'T'f' ORTQWPo.I
<br />
<br />SlA'''E
<br />
<br />...
<br />
<br />28<l PRONOUNCED DEI\D 1,*",,1
<br />
<br />"
<br />
<br />Dr. Jphn vanMatr~rJ..~s..._-..Has.ti.nga_..NehraRka f\R9.01 L.n?-4hl-5.. ?61 _
<br />32. REGIS1...R _ _ 1"'" DATe F'LED BV ji:'h~AR iliif _ ~I
<br />~._--~----- ______.____H L JUN 24 1996__
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