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86-100483 <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 />, <br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DtPARkEDM" OF'HEALTH <br />BUREAU OF VITAL STATISTICS, WHICH Is THE LEGAl.'VtPOtITORY'F0k' <br />VITAL RECORDS. <br />DATE OF ISSUANCE <br />JAN 1986 <br />STANLty,,'S..,,CobPtR; :'DIRECTOR :'DIRECTOR CTOR <br />2 1 <br />LINCOLN, NEBRASKA BUREAU OF, - V#AL STATISTICS <br />Fp='*&-'llAVW9h;MGZNCr DIF -6F RZAISH 50-UO499t <br />PUSUC NZALTH SlMyICX Bureau 09 vital stausaft <br />wrm NO. CERTMCATE OF DEATH irrATx ma No. <br />2. demand It <br />XTATX 16 <br />7 <br />a. Gomm <br />L a. Crrr If <br />b. crry o 46 f TH 0 hm OR <br />t <br />A TO <br />dL. D 111 earl, <br />I <br />d. <br />HOSPIT <br />IN ON 2 4. VATZ (Mosith) (Day) IT—)-. <br />KANN or <br />ol oll DtiATH <br />pdo) <br />;14-- ZZ <br />MA <br />IL ATZ OF 9. Ass (to <br />Iffist ) <br />H URAW If USAW to VIM <br />ism Items XhL <br />— <br />I <br />AA to C11 - of WMAT <br />PAT�ION of vo�i�4 RUSIN Y? <br />as. Us At, DIV PLA <br />dyad, E" 49 it A. <br />14L of WD X—?19�011 <br />1 146 IT. <br />xc"qm low or dame of servise <br />Yob a% or MAN 7016 <br />it. CAUM OF DRATH XEDIQLL GEM <br />m 3 L DIWASS OR CONDITION <br />sae toe W. IL). TO) DIRIMLY LZ&OINO TO MATH. <br />ANTZC=ZNT CAUSZO DUZZ TO (►) <br />Norbid modkised. K my, W <br />S) "*dse <br />"9b* =lr"W*7sd=h X <br />'iM <br />O* DUM TO (C) <br />f it. OTHzR SIGNMCANT CONDITIONS <br />Conditions costribsting to the death but met <br />to the disease or condition esselaff doatk. <br />rds"d 20. AUTOPSY? <br />1 sis. vATZ Or OP 39L X"OR FINDINGS OF orMATIoN WON <br />No <br />O TM <br />21a. ACCMZNT (99"y) <br />Ilk. 0 JURY in or abnt <br />=C13I.-FIX Arm% of in b". et&) <br />TOWN) (COUNTY) (STATZ) <br />Ile.('(CtTY OR TORN) <br />RURAL) <br />xOritClDs <br />21Z.- —INJURY OCCUNW 21t. NOW DID INJURY OCCUR? <br />aid. Tins (bleffith) (Dsy) (Yeer) (Now) W►Alo ■t Work 0 <br />INJ(lSTi to ID Net Wblis t work: <br />z:F IJJAO. f*2.0_K* IsSo, that Z Use saw d4l- <br />SLI hereby CatilY hat I attended the deceased ... ... ',W-Al—, <br />the causes and on the date stated above. <br />death occurred at "L, troft <br />ceased aN" pt, 29 and that U& DATZ SIGNXD <br />lie. TIJ� at UuqL Is <br />Ida U I DA <br />ON! it <br />C- <br />0 <br />i. <br />ary <br />