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<br />200802035 <br /> <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STA TE DEPARTMENT OF HEAL TH, <br />"CERTIFIES THE BELOW TO BE A TRUE COPY OF AN ORIGINAL RECORD ON FILE W"H THE STA TE <br />DEPARTMENT OF HEALTH, BUREAU OF V"AL STATISTICS, WHICH IS THE LEGAL DEPOS"O/(Y FOR <br /> <br />:~;;::~::::~CE ~.-i~~~ <br />ST. - $-.COOPER, <br />SEP 1 1995 ASSISTANT ft- Ttk5iISTRAR- <br />LINCOLN, NEBRASKA NEBRASKA DEPAlffMENJJ!fHEA~!f!c <br /> <br />~ <br /> <br />STATE OF NEBRASKA - DEPARTMENT OF HEAL fH <br />BUREAU OF VITAL STATISTICS- <br />CERTIFICATE OF DEATH <br /> <br />Nebr. <br />10 RACE -(..g_. WMo.l3lack. A~ Foci..n <br />""ISI>o<~i te <br /> <br /> <br />male <br /> <br />3}lATI' OO'[)EAT~J~.~ Y_I <br />c -..o-.:Wg . :~ 4~:==i 99 5 <br />6. DATE Of BIRTH 1__ Day. Y_I <br /> <br />1. DECWENT. NAME <br /> <br />FIRST <br /> <br />U100LE <br /> <br />l.AST <br /> <br />2 SEX <br /> <br />Dcminic D. <br />4. CITY AND STATE Of BIRTH INnd;, USA. """'" coun/ry) <br /> <br />UNll€R 1 VEAR <br />51>. MOS. DAVS <br /> <br />Aug. 4, 1915 <br /> <br />Schuyler, Ne. <br />.. 7. SOCIAL $ECURTlV NUMBER <br /> <br />:~ 482-14-2877 <br />:~FACiliTY - Name 1/1"'" m_. 9"'" _ aMnumbBrl <br /> <br />:~ St. Elizabeth Hosp.:L tal <br />Il< CITY TOWN OR lOCATION OF DEATH <br /> <br />ER Clulpaben, <br />DOA <br /> <br />OTHER 0 Nu",,,,, Home <br /> 0 Residence <br /> 0 ~flS(;Jec11v1 <br /> <br />HOSPITAL 1_ <br /> <br />8d INSIDE CITY LIMITS <br /> <br />Lincoln <br />9a RESIDENCE - STATE 9t> COUNTY <br /> <br />Lancaster <br />9<' STREET AND NUMBER I~Zip~) <br /> <br />lie INSIDE CITY LIMITS <br /> <br />y..KJ No 0 <br />13. NAME Of SPOUSE 1""'''',_'''''''''''_1 <br /> <br />Arrerican <br /> <br />'" USUAL OCCUPATION IG,...,,",oI__""""'J~ <br />0..1 01_"'9__/1_, <br />:::::I construction worker <br />n. 16. FATHER. NAME FIRST <br />.-.. <br />'41 Jose h <br />. 18 WAS DECEASED EVER IN u.s_ ARMED FORCES? <br />IV... "". '" "'*-1 I" yes_ _ w.r and d.... 01_1 <br />WWII 3-19-42 11-29-45 Tillie Hrub <br />MAILING lIDDRESS ISTREET OR RF.D. NO.. CITY OR TOWN. ST lITE_ ZIp) <br /> <br />MtOOLE <br /> <br />construction <br />l.AST 17 MOTHER <br /> <br /> <br />Tillie Dostal <br />15 EOUCATlON ISpocrly onty ~ll'ado eomplalod) <br />EIe~"'_ry 10-121 COIIoge 11.4",5"' <br /> <br />MIDOlE MlIlDEN SURNAME <br /> <br />Hrub <br /> <br />Veronica <br /> <br />Tc::ro:::ak <br /> <br /> <br /> <br />21b. DlITE <br /> <br />2'e. CEMETERY OR CREMATORy - NJlME <br /> <br />o FIomov.1 8-29-95 Grand Island Cit <br />21d. CEMETERY OR CREMlITQRY lOCllTlON CITY OR TOWN <br /> <br />Cemetery <br />STATE <br /> <br />Butherus -Maser---"!i~- <br />22b. FUNERJIl HQI,IE lIDORESS ISTREET OR RF.D_ NO.. CITY OR TOWN. STlIR ZIp) <br /> <br />_n...__~ <br />L.f"""'""" . <br /> <br />Grand <br /> <br />,--~.'--...,----.....,-_. ._-". <br /> <br />sland Ne. <br /> <br />". <br />., <br />. <br />.. <br />. <br /> <br /> <br />(bl ~~ <br /> <br />- ouCho OR liS A CONSEOU(llcE OF , <br /> <br />j~~.m <br /> <br />I Inter\'al betINen onset: ana oeatt'l <br /> <br />:~ <br /> <br />I Interval between onser ancl de~th <br />I <br />I <br />I <br />25 WAS CASE REFERRED TO MEDICAL <br />EXlIMI"ER OR CORONER' <br /> <br /> 2tIO <br /> 0 Ace....... 0 Undetermr'I(tCI <br />) 0 S"",'" 0 Pendll'M) 260. INJuRY liT WORK <br />0 Homoc'" 10_ y"O NoD <br />'} 270. DATE OF OEATH lMo Day. Yr_1 <br /> <br /> <br />26g. LOCllTlON <br /> <br />STREET OR R.F.D. NO <br /> <br />CITY OR TOWN <br /> <br />STlITE <br /> <br />28a. DArE SIGNED (Mo.. Day. y,.) <br /> <br />28b TIME Of OElI TH <br /> <br />.-.. .; ~ <br />'!II I ~ <br />~ !li <br />=d <br />n. <br />,.. <br /> <br /> <br />""~'" <br />I i 28C PRONOuNCED DEliO lMo. D"y. Yo 28d. PRONOuNCED DEAD 1'*"'" <br />!:h <br /> <br />M ~ ~ ~ 28e. On 1he ba~ of 6x~mms.llcn ~!l~ Of iIl~, '" my opinj()l'l oe~tl1 occl..lll"ed (;II <br />8 <5 the hme, ~ and place and due 10 me caJ!iels) ~. <br /> <br />""</ onlTln. .. <br />THE DEli TH? OR TISSUE DONA T10N &EN CONSIDERED' <br /> <br />)?Q UNKNOWN 0 YES ~. NO <br /> <br />31 "liME AND J\OORESS Of CERTIFIER /PHYSICIAN. CORONERS PHYSICIAN OR COUNTY lITTORNEY, IT.". ~ Pmt1 <br /> <br />_IA, <br /> <br />Au ust 24 1995 <br />27b OllTE SIGNED I"'" Day. Yrl <br /> <br />M <br /> <br />30.~ WlIS CQtjSENT GRJ\NTED' <br /> <br />o YES <br /> <br />David B. <br />32a REGlSTRJ\R <br /> <br />