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r WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE <br />I 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 ,� ll" <br />APR 1 .'�S STANLEY S. 'COOPER, DIRECTOR <br />LINCOLN, NEBRASKA BUREAU OF VITAL STATISTICS <br />PHS- 7311I1VS) MM. 4-37 <br />DcrAIITR[LNT or Pusiac tuwzTH. <br />t9UCA71ON AND VNICLTARIC <br />STATE OF NEBRASKA <br />DEPARTMENT Or HEALTH <br />Bureau ML Vital slatimIiIns <br />8 - 101674 <br />elz 130)01) <br />snrm no. 126.. CERTIFICATE <br />OF DEATH STATIC rtl IC <br />1. K/196 N afAT11 <br />a COUNTY // <br />2. WYK a[SEaR1eCCIWAw•�.11r. II.w.N+...: 11•lew..•/w -• -' -- ) <br />.. STATE 3. COUNTY <br />�• f 3 y <br />1. 0".. 011 TOM <br />t_ LENGTH OF STA MI IA <br />e. Cm. TOWR.1041 LOCATION <br />l RAMS (w , 0& Yrilf •dhee) <br />!. STREET ADDRESS <br />mos"TAL OR <br />INSTITUTION <br />O <br />r. K RELDENC£ INSIDE OTY LIMITSr TES 1• FARM RESID[NCE1 TES <br />NO ❑ NO <br />"'At NII1G Z w <br />9 <br />A DATE A/wt► Df V w <br />L `/ <br />ti/• 6 A <br />Ku—su—^L <br />or <br />DEATH a - / 9G 6 <br />E COLOR OR RACE <br />17y <br />7 MARRIED 93 h[KR MAMAKO • DATE Of PATH <br />S AGE [tKe <br />• IMDIR t TLAR <br />UNDER 11 <br />-(L!R <br />let �.•fAf1) <br />A/_N <br />WIDOWED0 DIVORCED � _. <br />."i <br />. ATIDN (Olrr l(I,N of wA Ae.e <br />Mb RINOOF OUS&NESSORWOUSTAY 11 RMTHPLACE (ST.(r K f«ei1N t••.r•1) <br />] CITNIDI Or ~T mIP 11 <br />d•f.1 RMM y wtsR1 h/r. rKR of rellrM <br />fp <br />IS& 1ATNEA'S NAM[ <br />I3D. MOTHER'S MAIOEII NAME It. <br />YY' <br />NAME or NUSRAMO OR WIfEARilidiaoii <br />1 WAS DECEASE R N1 U. S. ARM[D PoRCESf K SECURITY MO, F7 LgarAKT A//•r« <br />IYw. r. ..A-0 ill W Mw.-4. ,1 —0 <br />c5- 3 <br />1kw L <br />it LAW[ AK "AVM (C•Mr old/ -W ammm M I"m pr (.). (N. f.A It) -I INTERVAL M[TMEtM <br />PART 1. DEATH WAS CAUSED ITT. 0"31" ANO Du H <br />IMMEDIATE CAUSE (u <br />n <br />CbRf(11RM1. 1 /fM /. Om To (i) <br />VIN" pre rYr 4 <br />","- "t .Rlfr• Dug To (t) <br />111.1 r..K lad. <br />PART <br />N. ONNIN SIGIOnCANT COMM"0113 CONIRIEYfIM TO DLATH A)T MOT RELATED TD THE TEMI.ML OHEASE Comm" GKEM "PART 1(S) . W AS • Y <br />- KIWORMEDI <br />U <br />YES NO D <br />I= Me. ACCIDENT SUICIOE HOMICIDE LOA. OESCRIRE NOW MUURV OCCVRRtO fESYK .•tve •f1 iR Pfrf l M Par: Ir y .. !1.) <br />` <br />V O D — ❑ —� <br />V <br />j <br />3k TIME OF HfMr NwIR. On year <br />3 <br />MU1)RT M. M. . <br />S <br />P... <br />2E/ MIiWIT <br />O[CURRto M. WAGE Dr NUVRT lf. /.. b •/ Nf-w Lev, Xf OTT. TOWN. OR LOCATION COUNT' STATE <br />OMK AT D ❑ /fre' /fderl, xrrd . M11 -. ett.) <br />T AT iroN <br />_) 1.tt.rldod ttw dfw.t dfro— . r• •nd ber w. on <br />Q��1yt�.li- <br />Df.fN ooeMlrN at won tM e1.1. ft.t.d Aio•e; fnd t• th• D••f R< RRl Aaw.Hd/•, from Nh. "— •r.e•d. <br />(De1rK K ) <br />ROSS <br />77[. GATE SIGNED <br />Eif. EUMAL. CRl1MTM.L <br />MD. DATE <br />M NAME Of CEM(TERV OR CREMATORY <br />231. LOCATION (CW1._ /wN. •r n R/P) (a'•M) <br />REMOVAF (.l►eeyPl <br />I1 -2 -196 <br />''fs H C1O i4TRA <br />owc <br />7A.1 E O�O•RlTuUAaRY A001ESS <br />96M5 <br />� �.� <br />Rl� zy,1 %tL.r. <br />I <br />_-j <br />