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rWHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA. STATE <br />DEPARTHENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COPY <br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEP" T :OF JFALTH <br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DVOSITORY FOR <br />VITAL RECORDS. ' <br />DATE OF ISSUANCE . <br />MA 12W STANLEY S'..,COOPE$.,- DIRECTOR <br />LINCOLN, NEBRASKA - BUREAU OF VIi'kL',ST1ATISTICS <br />87! 102030 <br />PAU Of IRORAW- OHAAT110T Of" M.TN <br />NOW Of VITAL STATISM 86 14260 <br />CERTIFICATE OF DEATH <br />_ JAME u (Aa.. Dn. T.. f <br />Charles Claude Dickson 1, Male December 3, 1986 <br />_( AMriN• N.D..RNIM. /M..(p•. - I..I+rIMA I UNDE 1 VIM] UNIMICAY DATEOERMTH(M...D.T,TrJ <br />. ,• M,. O.Tr•..11.1riR«(h) Q nn.)69 ., tw DA MDK. Jan. 11, 1917 <br />CFTT AND STATE OF INGTH f •M i. L. .A.. WNA . N IK . Di» w.ill.w.••r) <br />w.... „) WIDOWED. ED(Sy.N(,) <br />Call,away, Nebraska 9. U.S.A. ID, Married 11. Mary Bruhn <br />sock" NYMDER VSYAL OCCWATION(GM Si.I d•.d b..♦..i.D -0 RIND Dup"In on INDUSTRY COUNTY Of DEATH <br />Agricu }tuna e!! uaT T <br />Cm. TOWN OD EDCATION OE DEATH <br />043001 CITY WARS <br />HOSPITAL OTHER INSn1UT10N -Nw <br />0.4.4WI.•.. r I.. "—Is. *) <br />(Sr.NEEYMrN.) <br />Dlw T/r.N•wi •..D../ <br />I Memorial Hos In atient <br />14r. Yes <br />1 .Grand Island . I•.. <br />RRSgENCR -STATE COUNEr <br />Cm. TOWN OR LOCAT101e <br />STREET AND NUMEEE <br />NUDE CRY Mars <br />(SV.T+b tires"') <br />1s.. 1st Hall <br />Is,. Grand Island <br />tar. 667 E. Groff <br />/s.. _ <br />N - N <br />s A. Dickson <br />Stella -- Huffman <br />WAS DD... r4 MI u.i. ANMID Tones <br />NMoYAAW- NAME- RELATAONSNN- A1AKWJG ADDRESS (STNET OE R.1A. NO. CRY OR TOWN. STAIR. SM) <br />CY.� »... WAR tR 1•. R..... wd a... w .. +.I <br />Dickson- Wife -667 E. Groff -Grand Zaland, NE. 68801 <br />1a No <br />RUSAL Cm.000% <br />/TMs <br />CEMETM OR CRRMATORT -NAME LOCATION CHTORTOWN STATE <br />ec. 8, 1986 <br />TD,- <br />».. Grand IslAand Cemetery so+. Grand Island NE. <br />- Y 3 d <br />A1 - RNAAH ND ADMU (MM p R.P.P. ND.. CITY q POWK STATI. Mn <br />EA fel- Butler - Geddes 1123 W. 2nd Grand Island, NE. 688( <br />DAR 4WINLAW (M.. Dow. 71. <br />(Z. D.P. Y.-) <br />E WIN <br />December 3 1986 <br />T... <br />Ee►. M <br />►RONOUNCE D MAD <br />►RONOUN CEDDE AD(H —) <br />y <br />i <br />(A%.. D.I. Y. ) <br />12 -10 -86 sk <br />. 2:12 P.M. M <br />V i <br />i8 <br />1 <br />R•.•I•ti• IR. ti .•A i <br />A ... .. M <br />M <br />M/' • <br />• iIs. <br />•.�, MN ..d 01we d M w M • 61.M•A <br />i <br />NAM AMANIUSSOPCIETWO&APHIMMM. rNr IW AR ET) (r,p e. Print) <br />. V. Reiss M. D. 2444 Faidley Grand Island NE. 68801 <br />DATE RECEIVED RY RE ISTRAS (M... D.Y. Y"I <br />DEC 15 1W <br />{ <br />( CHET ONFCAUSf PER 18W RRI (.). (b. AND (4) W—W r.e.. «.•..I «+ti•+ <br />Cardio-pulmonary failure <br />.N..d`........�....«» <br />Pblt"o^pv"'RGUFRE'6'-Gas-trocolic fustula secondary to Gastric <br />1 month <br />M <br />DUE to. OR AS A CONSEpUENCE OE: x.N..d ►a.......w ..1 d..w <br />hat -c"�' "`• °A"'� ~� �'~ � T 61KMK' NIA " 7NA� IAMI �> �Ar i« « N.! <br />1 OfN•�ORONItO MOKAI <br />M NO <br />1-0 N. O xR <br />r «. wl NO <br />uIIRRT . <br />WNW .MIR'T HAC. D•I. Tr.1 <br />NOl1R d N.uf/ <br />DNC.NE NOW •uuRT oecuMeO <br />a NNMtl.EMN10A1101a tT..�•i! <br />_A, ,•..,, <br />SUM a..I.D. N.. tlR an TOWN sun <br />MbL <br />rRD. D.MMy +. TN.eYS) <br />STATE OF NEBRASKA, County of + <br />Filed for record and entered in Numerical Index on 19 <br />o'clock �.M., and recorded in Deed Record , Page <br />County 5T Ei�puty unty er <br />Register or Deputy Register of reds <br />5.5 <br />1 <br />ti- <br />R <br />