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WHEN THIS COPY CARRIES THE RAISER SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH. IT CERTIFIES THE BELOW TO BE A TRUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEZPBRIXENIT OF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY FOR
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />NOV 1 STANLU S. COOPER, DIRECTOR �il
<br />LINCOLN, NEBRASKA BUREAU QUVITA? STATISTICS
<br />STATE OF AE SKA- 9E►ARTMEMT OF HEARTH ••• 113058 5
<br />OOORAO OF YITIA STATISTICS
<br />COO RCATE OF DATM } �
<br />DECRE -NAME tow M 'S E (DATE OE DEATH (AM., Dr.,. Tr.) -�-
<br />I Elmer George Lon ,Male is October 12, 1986
<br />VMft, ihTk, ANSrea1 OMGIN/DESClNTh -1 . Nelien. Mwi.es, AGE -Iw RixAM, L UNDER t YEA/ UNM! I DAY DAR OF iRRH fAIS.. Der. r, )
<br />h.h-._j ISp.riiTl Gsr�w., erc.)!s�«ilf) nnSS fYn.l MOS. DA S HOURS .NHS.
<br />tit.i rm Arenr-(non FfV 7, �.. �._ I - Morph 11 1077
<br />CITY AND STATE OF DRM (IF nee iA U.S.A..
<br />CITIZEN OF *"AT COUNTRY "Aroma. "EVER MARRED,
<br />MAAIE OF SPOUSE 1N siF.. /iw .ISid.r ee.N)
<br />•....rwe,I
<br />-n 0. DIVORCED (sP-40
<br />Y ONE PAUSE IWIRF
<br />&1.u4
<br />i. ou Nebrask
<br />F U.S.A. Io Married
<br />11 Audrev W. Petersen
<br />SOCML SECURITY MUANR USNAI OCCtIMT10N (Giw Siwd e! wrS dsrw derirp .rrsrr 1 RIND OE DUSINESS OR MOUSTRT
<br />cIi4.
<br />COUwTY CE DEATH
<br />A3w-A`
<br />SNIw :/rN:red1
<br />)A) Lift A D r (5 6 Ly 1
<br />,2 u.. Farmer 176. Farming
<br />,.. Hall
<br />CITY, TOWN OR LOCATION OF MATH
<br />0111M CRY ~S
<br />"CIS ►RAL OR OTHER MSTRUTION -N— (If rrM:. *roA-, N.IORr DR
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<br />yi.. arrssl end w..d...l OSlrsr�.rll... b . ,+PSwwr rlwr/r.
<br />I
<br />I.r. Grand s' an
<br />1.1. Yes
<br />I.w St. Francis Medical Center ,.e. Inpatient
<br />RESIDENCE -STATE COUNTY CITY, TOWN OE LOCATION STEEET AND "U"M
<br />INSIDE CITY 1WTs
<br />I>.. ras 27Y. Hall IS, Grand Island Tid. 2611 West Koeni
<br />rsP.riF,
<br />s. Yes
<br />�Ti. Henry -- Long !n Frieda -- Letterman
<br />WAS DECEASED EVER IN U.S. AWED FORCES? i INFOMIANT- MAW - &RATIONSHIP- MAILING ADDRESS (STREET DR i.1 D..0. cm 00 TOWN, Sun, 1N)
<br />Is.?10 II+.Audrev W. Long-Wife-2611 W. Koenig-Grand Island, NE.68801
<br />iURIAI. CrSMelisr, RSAIe.sl I Ciomuny OR CREMAToIY -NAME LOCATION CRT of TOWN STATE
<br />is Oct. 15, 1986 '� Grand Island Cemetery 2Dd. Grand Island, Nebraska
<br />- SIGNATFAK L UCHd NO. 7L.? FUNERAL HOME -NAME AND ADDRESS (STEM OR AI .D NO.. CRT'OR DOWN, ST.K. ZN,
<br />a.7 22.Apfe1- Butler- Geddes 1123 W_ 2nd, Grand Island, NE. 68801
<br />Allow OF DEATH FAR.., M. Yr.l
<br />_r DATE (w.. D.F. Y'.) NOU/ OF MATH
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<br />Accfa / _Swool, NOYCOL Loom. : DATE OF N1rYM 1r Dn. V. I HqN oF 1W Un DESCME HOM' MUYM mcuum
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