k
<br />4
<br />WHEN THIS COPY CARRIES THE RAISED 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 DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY tOR -
<br />VITAL RECORDS.
<br />87-101570
<br />0
<br />DATE OF ISSUANCE '/ '
<br />1 2 W STANLEY S. COOPER, DIJWTOR
<br />LINCOLN, NEBRASKA - BUREAU OF VITAA BTAMTICS -�
<br />STATE OF NEORASKA- DEPARTMENT OF HEALTH
<br />WREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH_
<br />DECEDENT -NIWE AEST ISO DATE OF DEATH (AA . O.I, VI.) -
<br />, Genevieve Mable Koffke Fesmalh February 28, 1987
<br />PACE- (..y., WAi1.. A, Ar.k,. OtlGUyDESCENT b.E.. Md:s.. At.. AGE- I.,+WM,I UIOE! in" UAIDR i par DATt OP RIRTM(M... D.r -r.J
<br />I.w:,...4j(So -or) G..,.,ee,) .rxp a...) ro: DAIS HOURS. MR7S. November 15, 1908
<br />White American w. 78 6. 1,.
<br />November
<br />CITY AND STATf Of BIRTH (M ... t. U.S.A. ) CITHEN MN OF WHAT COUNT" . NE MAtl SE (ED. NAME OF SPOU (x-ft.
<br />1 WIDOWED. DrrORCfD(Sp-dr) t
<br />ECarmeI tovnshipMiO"aio U.S.A. to Married Irr, Clark Koffke
<br />SOCW MCURHT MDYE! USUAL yOqCCUTAtION (G:.. ki./.(...L M 1•+r�R "•w O<RilAr055O[ INDUAlr COUNTr m DEATH
<br />12 376 -14 -6241 1],LerYc typist, Wash. D. C. ��gugS�d Hall
<br />CITY. TOWN of IoutIGN GI DEATH INSroe cm Luun rgSNTAL W ot,l@ watinUTrO,) _..... tx-r:. «Mr.
<br />. MDY. w.0""-00'
<br />(SRrJIrwrMN pr w...rM..ir
<br />,r Grand Island NE IAI.Yes Ta.GraMd Island Memorial ,.,, Inpatient
<br />RESpENCE -STATE COUNTY C/rr.TOWNORLOCATION slowANO M{WRU - RMSME CGrlYYR
<br />tS�d. rsr.�tN
<br />I s.. Nebraska ISY. Hall Ix. Grand Island ISa 2125 W. 13
<br />A _ 1151 Ahlom LAW
<br />1 Marshall Kell Cora Belle Case
<br />WAS DECEASED "m M U.S. AWED PORCEST 1Nt04MMt- NAME- lttAtg2NS,s- MARlSG AODR[SS (A!R Ol tl s ,rD_ tli+ YA2 DPI
<br />u. No I IP Clark F. Koffke (husband) 2126 W. 13 Grand Is , Ne
<br />EutlAI C....r...Rr.,Mi CEM[TER7 ORCRE,IATORr -NA/,E EOCATIOM Cm N covoW STATE
<br />x.. Burial m March 6,1987 2&_Mapel Hill Cemetery 2,�Charlotte, Michigan
<br />-Slam i MO. FUNERAL HOME- NAME AM ADDRESS awn" OR U? rp., Cm of WeIH. SPA,! I"
<br />Livingston-Sondermann, 505 West Koenig, Grand Islaad,NE
<br />tE OF DEATH fm., . r..e (Ala be,. r..) HoOk OF OEM"
<br />February 28, 1987 `2v. 2.► ,.
<br />ra PRONOIMKW DEAD rROE(o(n+CED OEAD(Fl..d
<br />r !
<br />DATE SIGNED` 0". )rnA
<br />3-5-$7 2k_ 4 9 P.M.
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<br />' _rs,...�..r RMN I• r I 2AarSy..., +.r rwr►
<br />C COON" ATTOb,Eq
<br />J. V. REISS, M.D., P.O. BOX 550 Grand Island HE 68802
<br />0. a ql 041E RECESM® w REGGIISTRAR (Me- Del, r..1
<br />(FAIM OMW ONE CAUSE FIR WN I= (,1(161 AND OM A.wriArr..rr,r► Ar►
<br />Pali
<br />Myocardial Infarction
<br />DUE A Em: A,r..iSr..r rnrrw l..4
<br />d Lon Ntory of Congestive Heart Failure
<br />OUF r0. OR AS A CONSEQUENCE m
<br />S- .—I V T.Lm . : —TO.S+ r.i CA,e MTelD q MWITAI
<br />THE MST,' M—eem ON CoRDNiR
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