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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 />l BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSTTORY,`PQRY <br />l VITAL RECORDS. , y <br />DATE OF ISSUANCE' I <br />©E � 2 31985 � A -�.._. <br />STANLETA iar, P41MT6A <br />LINCOLN, NEBRASKA BUREAU OF Y7'R Its <br />,' <br />STATE OF NEMASNA- DEPARTMENT OF NEALTH <br />DUREAU OF VITAL STATISTICS 4,7- S 64- 5 <br />CERTIFICATE OF DEATH 0. un r wd, 4 fPAN <br />DECEDENT -NAME FIRST MEDDLE LAST <br />SEX <br />DATE Of DEAN (M.., D.Y. III) <br />1. Mildred Marguerite Powell <br />Female I <br />3. December 13, .1985 <br />RACE -N.y. whi,.. BLaci, AMalkaw O 40041DESCENT(•.R., I.6— M•rirew, AGE- &+ II y <br />UNDER I YEAR! UNDER I DAY DATE Of RNRN /M•.. D.P. 7, 1 <br />Iwdi a(SpaTiEY) I.RNaRw, dt.)(SR•Tifp) lYn./ <br />�i7hite a American 16.. 66 <br />MOs. DAYS I NODES • MINK. <br />6b 6. ;May 4 , 1919 <br />CITY AND STATE OF Stiff" IN .# I. U.S.A., <br />CITIZEN OF WHAT COUNTRY MARRIED. NEVER MARRIED. <br />NAME q SI.pU fNrU•. R^a «aid.w wa«.1 <br />E. rfa�aaia, Nebraska <br />R USA DD1 vaElrr ORCEOrsl,.riry) <br />Thomas M. Powell <br />SOCIAL SECURITY NUMBER USUAL OCCUM110N (Gi.►liwdd. art dew• dari.q �.., <br />KIND2q BUSINESS OR INDUSTRY COUNT? q D(ATN <br />•E )if•, Ynfindl <br />12 508 -26 -4876 17ar�oema'�C"er <br />13b. Home ,N Adams <br />CITY, TOWN OR LOCATION OF MATH <br />INSIDE CITY LIMITS. HOSfITAIgOTNER tNSTI7UT10N- NeM•(1 /wer.w«r6•.. NNDS• DENS' "w—DOA, <br />1.6 Hastings, Nebraska <br />(S Y•, -N•) Ei ..•EOwd Mr) D...I_n /1... Rw ....w... fsn «.I1r <br />1.°�l�s 1idi�ary fanning Hospital Inpatient <br />RESIDENCE -STATE COUNTY <br />CITY, TOWN OR/OCATION STREET AND NUMBER <br />INSIDE CITY LIMITS <br />Nebraska Hall <br />1So. us. <br />Grand Island I 1507 North Custer <br />lk. 13d. <br />(5i tes�NeJ <br />13♦. <br />AT R -NAME . I MI UST <br />M07HER- MAIDEN NAME 1195 MIDDLE LAST <br />Daniel A. Theasmeyer <br />„ Dorethea S. Meyer <br />lt. 1YY 1Thomas Pow sband 1507 N. .IS er„ Grand Island 1 <br />BURIAL. Cnro6— ReM 1 DA E tCEfTEMY OR CREMATORY -NAME i LOCATION CIY OR TOWN STAVE <br />zoe Burial 2.pec. 16, 1985 �2,Lincoln Memorial Park I2DdLincoln, Nebraska <br />' EMBALMER nNATURE A LICENSE NO. :L 0 IUNERM HOME -NAME AND ADDRESS 1511111 01 11 D HO. 11" DR 10w . 11.11. 1.11 C V 800801 <br />� � // Anfol- R..rTnr_Cc A.ioc 1111 T.T ')-- C. <br />U07lll <br />PAM <br />DUE TO, .. <br />M j ) w­4 6•..+.n «.../ d- . <br />/ / <br />DUE TO, OR AS A CONSEQUENCE q: <br />07 <br />DATE q DEAT , De,, Yr.) <br />DATE SIGNED (Ab Doy. Y..) HOUR q DEATH - z <br />` <br />12.6 <br />Z_ <br />1' V <br />. »O <br />2•a. M <br />DATE SIGNED (Me., DsY, Yr.) OUR q MAIN <br />R <br />i� <br />fRONOUNCEDDEAD /RONOUNCED DEAD (M—) <br />—1,V Q <br />226. — (/ J 23[. y M <br />:'^t j <br />'bZ <br />I.... O.Y. Yr.) <br />2EC. <br />i� <br />2=O <br />T. 6.a. N 4..B —.rM .1 .w. •r, •I.a. aM d.. «.. <br />e <br />aw„p] .1•M. _ • /z <br />r D i <br />h..iar, .bN ra ehar <br />/J. /� <br />iJd.l%Yna.....�.i fiW)' / "•/IVC/ <br />24e. M,­#­ .MI o11l <br />_ <br />NAME <br />AND ADDRESS q ER 1 SICIA CORCINERS PHYSICIAN OR COUNTY ATI01INE17 <br />zl.n... •...a. <br />U07lll <br />PAM <br />DUE TO, .. <br />M j ) w­4 6•..+.n «.../ d- . <br />/ / <br />DUE TO, OR AS A CONSEQUENCE q: <br />07 <br />