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<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 FOR
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE &Pmw
<br />AUG 2 0 Off STANLEY S# COOPER,- DIRECTOR
<br />LINCOLN, NEBRASKA BUREAU OF VITAL- tTATISTICS
<br />STATE Of NEBRASKA — DEPARTMENT OF HEALTH
<br />BUREAU DF VITAL STATISTICS 85 00756
<br />CERTIFICATE OF DEATH - . 1,,; - V
<br />DECEDENT -NAME FIRST mime LAST
<br />HIT
<br />DATE OF 04ATH (AS., De,. Ycl
<br />1 e 3 J enae)!E
<br />Mal.
<br />J 2 196
<br />RACE -Wip.. White, !lock, A«e.ica CRIGIN(DfSCENT(e.B., Nelien,Meeken, AGE -Kew RinbNy
<br />UNDER I YEAS UNDER I OAT DATE Of O1RTN(Me.. De,, Y,.)
<br />IMien, •N. (Speeif,) Ge. . e cVsp•cif,I (Y.c.)
<br />AIDS. . DAYS NODES . MINS.
<br />4�hite 3 .h �a a ".
<br />,. May 92 1692
<br />CITY AND STATE Of OWTH (N IAN in U.$ A, CITIZEN W WHAT COLIN MAR fO. NNER MAR -ED, NAME OF SPOUSE (N -if., Ei.e nroiHw name/
<br />nl.,) VADOWfo,wv EorsPKify)
<br />IT St• Paul Kebraska . U.S.A. ,o ![arrliR it Dahlke
<br />TE Of DEATH (AQ, Dey, NJ -
<br />SOCIAL SECURITY NUMBER USUAL OCCUPATION (Gi.e kiM sl ews done dp.inB ewt NINDpi OU}SIN ON rJUSTRY COUNTY Of DEATH
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<br />1 Z. Ile riOian .% I76 . I N.
<br />CITY, TOWN OR LOCATION Of DEATH INSIDE CITY LIMITS
<br />HOSPITAL OR OTHER INSTITUTION - Name (If not in •ilh•, 11 NOSP O. MST 1Mum DOA.
<br />�� Island, `- ' "k (SPY TyMNo/
<br />IM_ (IK�r 4. j
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<br />Idd. AEis�.i�El�• 3t• Ja'EES � 11e.
<br />1
<br />RESIDENCE -STATE COUNTY
<br />CITY, TOWN OR LOCATION
<br />STREET AND NUMBER
<br />INSIDE GITT LIMITS
<br />51brask4 Hall
<br />Its, brand Island
<br />23 Ste
<br />:3b January 7 1985
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<br />Ue. 136.
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<br />Jorgensen+ IT A,(deo) Anna Hargarthe (risen
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<br />r WAS ED me IN U S. ARMED FORCES? I INFORMANT -NAME - RELATIONSHIP - MAILING ADDRESS (STIEII OR /1 D HO. CM O. TOWN. STATE. LIP)
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<br />IB No !
<br />j., Dammy JorgeoseKa3lu*43 31E Grand Tsi .> a _ No
<br />BURIAL, Ccenwtiee, Rep-1 DATE
<br />j CEMETERY OR CREMATORY - NAME LOCATION CITY OE TOWN STATE
<br />:o.. Bt3bia� ]ob 1 -Lj.8S
<br />_jm1 EiMWA CMete�_v 9t. Paul_ Nd ta•.stita
<br />EMBALMER -SIGNATURE A LICENSE NO -1 m a A I FUNERAL NOME -NAME AND ADDRESS (STREET W 1 f D NO. on D. TOWN. sTA . L1n
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<br />j,, Jaoobsen Funeral $are $li "ON 9tr. 9t. Paul Nebraska
<br />TE Of DEATH (AQ, Dey, NJ -
<br />DATE SIGNED (Me Doy. Yc.) IHOUR OF DEATH
<br />:1.. January 2, 1985
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<br />PRONOUNCED DEAD(Itwd
<br />(Me . D.P. Yr )
<br />3r KAt
<br />:3b January 7 1985
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<br />. 5:30 p.m.
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<br />CERTIFIER (PHT51CIAW.
<br />ICORONtW$ PHY31CIAN OR COUNTY ATTORNEY) (I,P, eI Pcinl)
<br />E3. David R. Colan, M.D.,
<br />�EEGISTRAR
<br />729 N. Custer, Grand Island, 68801 _
<br />7Ae.(fie• 11/ / '
<br />-([BEER
<br />DA EIVED OY REGISTRAR (Me, Day, Y..)
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