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STATE Of BUREAU OAF VITAL RTAATISTiCSF HEALTH 87. 103270
<br />CERTIFICATE OF DEATH
<br />`OFCfDEI+(� -'NAME - FIRST MIDDLE - to -
<br />SE1[
<br />OA -i•E -0;7 fATN
<br />1. VICTOR PHILLIPS
<br />2 M
<br />September 20, 1984
<br />RACE- (e.g.. mobil•, gl.e3, Ar.nc..
<br />lwdi.n, ak f3p•�;rr)
<br />OLIGIH /DESCENT (..q.; h.li.w, M..i..., AGf
<br />G.rw.w,.HV Pwifr) (T'.,
<br />-W1 R!, 4,
<br />-.
<br />UNDEE I YEAR UNDER t OAT DAIS Of silil" M D.P. Yr.)
<br />MOS. DAYS HOURS. MINS.
<br />. {ilite
<br />1. American Q� ...
<br />82
<br />.6. k. ?.July �0, 1902
<br />CITY AND STATE OF RUTH fff ..t in U.S.A. CITI2EN OF WHAT COUNTRY MAtRJE6,
<br />NEVER MARKED, - NAM[ OF SPOUSE (11
<br />WIDOWED.
<br />DIVQRC[D (SPw(h) -
<br />± Erna Nebraska P. U•5 A. I
<br />. Married
<br />SOCIAL SECURITY NUMREI USUAL OCCUPATION(Gi•. U.I.4 -6d... a.,:wq.r•1 LINO OF RUSIFES3 OR INDUSTRY COUHTT
<br />Union Pacific
<br />OF OEATN
<br />-
<br />li. - (�._ D e •ateber ub.
<br />12 -0 -6$1 ,.e:
<br />Hall
<br />CITY, TOWN 01 LOCATION OF DEATH
<br />INSIDE Citt 1 HOSNTAI OR OTHER INSTITUTION.-H.- (0-11. .4h., IF N011 O. INSt. I,c<n. nDA.
<br />FEES
<br />(SP..ifr iwwN.1 qr.. omt.s/..rb*,) 0.ge<:«NE.•, b, 4►.N• +l iSArF,1- -
<br />,A;_ Grand Island
<br />l.c. Yee ?sd. G.I. Memorial Hos ital 14.. In Patient
<br />RESIDENCE -SSATE COUN_TT CITY, TOWN OR LOCATION
<br />- STREET AND HUNKER SNS'DE C<iT LIMI,3
<br />�,3e.ftebraska Tab_ Hall u.. Grand Island
<br />t3a. 18 6 Wa 12th Street t3.. Yes_
<br />A(F NER -NAME FIRST MOTILE - LAST
<br />N NAME FIRST MIDDLE _ U
<br />IA-Andrew Philli s
<br />v Mary Rogers
<br />wAS DECEASED EVER IN V.S. ARMED FORCES?
<br />w «SI IN Ir. qi.� w W MN, N ,•„:<N
<br />INFORMNT- NAME - RELATIO NSHIP -
<br />-A I l . , 6 §; N , STATE, Iu)
<br />o11
<br />1E~No
<br />l Phli s Wif - 8
<br />RURIAE, C-fi... R.-Ij I?AT
<br />CEMETERY OR CREEEiiTORE -NAME
<br />LOCATION CITY OR TOWN STATE
<br />20.. Burial 206-Sept. 24 .1 984
<br />2D.. Grand
<br />ma. nd Nebra
<br />EM1A
<br />-SIGN IUR S iCFNSE No.
<br />FUNERAL HOME -M,WE AND ADORES IsiN[t a 1.F.g, NO.. C. 01 TOwN, suie. m 68801 -
<br />n.
<br />-
<br />32Livin n- Sondermann 505 W. Koenig Grand Island, NE
<br />DATE OF DEATH (A1.., Der, Y,.)
<br />z> DATE
<br />SIGNED (M.. D.r, Yr.)
<br />FOUR OF DEATH
<br />.S
<br />2]a 7-20"84
<br />w
<br />DATE SIGNED (AN., D.T. Yr.) HOUR
<br />OF DEATH
<br />DEAD
<br />►RONOUNCEDOEAD(N -)
<br />iii- PRONOUNCED
<br />Jn; 9`25-84 :2..
<br />1102 a.
<br />IMO.,
<br />D. ?. Y,.)
<br />?Ad,
<br />i1
<br />SIR 2..
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<br />.41e.:<N ...w:w.N•. .17.<iww.:l.Nr. :.h •.:Ww.•.M a <..wdN
<br />+•, .er W.4<.W. «rM•<.•rW ,rN
<br />1
<br />2...
<br />TS:pw•w •d fi.•1
<br />NAME
<br />AND ADO[f35 Of CERTIFIER I►NYSICiAN. [D1aNf t'S INYfIfIA m Cnt,NEY
<br />At2ntNYTI rt_.....
<br />.,,.,.
<br />T2t7. e- TMSA WDIA•ll CAUSE (E:JFR ONLY ONE CA' U-SE
<br />PER LINE FOR(.). (b), AND (U)
<br />PART
<br />IN Right lower lobe pneumonitis 24 hours
<br />EWE 10. OR AS A CONSEQUENCE Of: I.w•,.I A.<.... �„<�, •,. aNq,
<br />Ib<
<br />DUE TO, ON AS A CONSEQUENCE OF.
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE ABOVE 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 FOR
<br />VITAL RECORDS.
<br />� Issued Oct. 1, 1984
<br />DIRECTOR, BUREAU OF VITAL STATISTICS LINCOLN, NEBRASKA
<br />Exh 1 101-f %i `
<br />
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