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{„ (1 i) SSla�d Acics S <br />STATE r <br />suBEau OF vm►t sTAnmcs 87— 101407 <br />OF DEATH s <br />sGc <br />1 #C N -NAME FIRST mime UST SEX I <br />I D <br />I. J <br />RACE -N.S.. w6i1...leTk AwNi.e. OIIIGIN/DESCEMT(..S.,IMi.w , wv'Maa, AGE -Iw 4a6Aef UNDER TEAS UNDER tDAT DATE Of Silts (M... DeT. Yr.) e <br />j fwdie...k ­-%. . ( nee +eH )ric ! BAYS HOURS. MISTS. te s <br />ept <br />CITY AND STATE Of GOTH (P ..f k U.S.A . CiT/2EN OF WHAT COUNTY MA .NEVER MA[RIW; N <br />NAME OF SPOUSE (N.:f , 9me . id <br />eefrl ' <br />'- <br />t <br />.ea.Tw•fefl - WIDOWED. DIVpRCED (Sp.d(r) <br />l i 1D. � 1 <br />11. <br />SOCIAL SECURITY E! USUAL OCCUPATION (rim L..d.1-4 de.. dr.:.. reA RD4D OE W SINE55 OI DaDUSTRT- COUNTY OF DEATH <br />I2 17e- 176. IY. <br />C11T. WN 01 LOCATION Of DEATH INSIDE CITY LIMITS' H <br />HOSPITAL OR l/NSTIiiST10N -NSr .st )a.:fM.. oMOST. DE Dfst. DfL4 - <br />- <br />fSPKIA'Y_-Ne) R <br />R:.. . w+6 «1 O <br />1 14. XQ. I <br />IAd. <br />RE -STA E COUNTI CITY. TOWN OR LOCATION A <br />AND NUMSER INSIDE CRY LIMITS - - - <br />- <br />RnwPI-rw) . <br />IN 156. 1h. , <br />,Sd. <br />A - NANW--- FIRST T. _ - <br />Elmer �1 Mabel Johnson <br />WAS DECEASED EVER IN U.S AWED FORCES? 1 <br />1INFORMANT - <br />U. v <br />- <br />{ P 1982 'L 3 <br />3 - S/GEEAfUtE <br />is, FUNERAi HOME -NAME AND pSRtE1 pt Rf D Mo. Cm DR IO.fN. SIAN. M - <br />t h <br />h 2 <br />OAtE <br />DEATH (M... D•F Y..) - A ( D.r. ri.) j— DEATH - <br />- - <br />Il <br />I7A6 M <br />DATE SIGNED ( <br />- <br />(M._ D <br />- _ <br />276. i <br />.( SW N.. M <br />IOAMF AND OF CHTUIER 7NTSICtm. umo"I" PHTwLAN on COUNT? Anofte ) ffEP..• P••.f) - - - <br />- J <br />;DATE RECUVW BY REGISTW (A", Der. Y..) <br />L:f - <br />'. ( <br />(ENTER ONLY ONE Pjf a:A, f6i_ AND (c/) wr..16...w..rr ai 4r6 - <br />T �\ <br />r IllalN ♦ MOs _TIKF a ..)URY- L W, Iw..wr. (. ere. IIDCAMOM ST oR"D .1. CSR M NNIN WISE - <br />. <br />3Sol. 70.. - <br />WHEAT THIS _COPY - CARRIES THE RAISED SEAL OF THE NEBRASKA <br />STATE.DBWARTMiNT OF HEALTH, IT CERTIFIES THE ABOVE TO BE <br />A. -TRUE COPY_ Off? -_AN ORIGINAL RECORD ON FILE WITH THE STATE <br />DEPARTMENT OF"HEALTH, BUREAU OF VITAL STATISTICS, WHICH <br />IS THE LE'LGAIe DEPOSITORY FOR VITAL RECORDS. <br />DIRECTOR OF VITAL STATISTICS AND ASSISTANT STATE REGISTRAR <br />LINCOLN, NEBRASKA Issued August 12, 1982 <br />L L � <br />