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6
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRITE COPY `
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL.DEPOSITORY FOR
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />DEC DE i STANLEY -S,- COOPER, DIRECTOR
<br />LINCOLN, NEBRASKA BUREAU OF VITAL STATISTICS
<br />STATE OF NEMASUA— KFART1KpT OF HEALTH 87-RD S39
<br />NHtM OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH—,.
<br />RMQ -N.f.. WFiN. RNck, A»wN.. pIGIN(DESCl NT (. f., Ir.li.•,1 .ire••. 1 AGE - -IAV• A. __ I UNDER 1 YEA"' UNDER 1 DAY I DATE OF NRTH (u.. D..T, Y. )
<br />W.. N jJ sp.lily) f'.e..w », Nc.l fS..YIr1 rrn) Aqf. DAYS 1 HOURS - "IN
<br />S -
<br />LTT,; +o _ r.aT mn[, 10 �� 7A lA. L 29 IA, - - T June A. 1910
<br />AND STATE OF DAY" (0 nN i U.S I_
<br />E.ITIEEN OF WHAT COUNTRY MARNED, NEVff MARNID, I NAME OF SPOUSE (N�ih. fiw •w.iHn... I
<br />rwAwrJ
<br />MC nd Island NE
<br />WIDOWED. DIVOICID (sp-jr)
<br />• U.S.A. ID Married (IIF. Grant Falmlen
<br />i SOCIAL StCWIrY NUMfff
<br />USUAL OCCUPAtIQN (hire I`d er.s.k lPM d.nwf .w.T KIND or DU WE SS W INOUSTET COUNTY Of DEATH
<br />Iz 06- 0 -07
<br />AE wrEiw f 7iE...w. i1 _M.dl
<br />,�. Retail Sales 'ISb Fertilizer Pl Hall
<br />CNR, TOWN Of LOCATION Of DEATH I INSIDE Cl" LIMITS
<br />NOSPITAI Of OTHER INSTITUTION - N..w Of e., i. wfP , , N NOW Of WIT IN..w• 004.
<br />Q•M••w•itr. Tr .w••w•fSew.,!
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<br />! uoGrand Island I «.Yes
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<br />Iw Grand Island Memorial Hos .l ».In atient- IcU
<br />RESIDENCE -STATE COUNTY
<br />CIT'. 10WNWlOCAT10N ST[IET AND NV/NEf { INSIDE CITY LIMITS
<br />Ne/
<br />�u.Nebraska Iq. Hall
<br />_ jlse Xes_
<br />Is.. Grand Island IsL210 W. State IS.. ye
<br />4 Ammond - Wicker Ir Unknown
<br />WAS OECE13lD EVER IN U S. ARMED fKElT - NAME -![(A TIONTHIP- AVLING ADDRESS (STMT CN f.I D NO. Cn >t tOw N, O S E 2
<br />Il'•e u w .NI IN •w. e•- wn w. a.N. M 1
<br />I,F. Grant Falmlen 2104 W. State, Grand Island.
<br />1. CEMETERY Of CREEAATORr - NAMf ' LOCATION CITY OR TOWN STATE
<br />' ion ,%Nov. 10, 1986��DY CNCS 12Dd Gibbon, NE _
<br />ENSE FIO. I FUNERAL NOME -NAME AND ADDRESS (slut? Of f r D NO. C•TY ON TOWH, $I.,[. CHI
<br />Miller
<br />and Godberson C +3 %3 °4 /+ t
<br />DATE SIGNED (w. Dey, 1,.7
<br />f OF DEATH
<br />,,.. November 9 1986
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<br />:s..November 10 1986 ,k 10: 1$ a.m.
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<br />NWE ANO ADDfE S CElTMIEt (EMYSICIAN, CORONER'S PHYSICIAN OR COUN
<br />AITORNf TI (Type w F,.M)
<br />J. Cannella M.D. P.O. Box
<br />2339, Grand Island NE 68802
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