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to <br />m <br />86— 101710 <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 <br />APR u ;986 STANLEY S. ,COOPER' .,DIRECTOR <br />LINCOLN, NEBRASKA BUREAU OF V'fAL;STATISTICS <br />Irxs- vs) Elsv. c •T "A" OF NtEHASKA <br />aQwxi I�Irr oT w•_ 2a >�►trs DeRAtl7AXISIT OF IMAL.TH <br />ZDUCATION AMP , ,"ARC fsMrran at Vito! ataiimi= <br />65 x+540 <br />lm1m NO. uf�JSL-;'—"LO CMTIIRCATZ <br />OF DZATH srATS MX <br />1. rRADL N ODATM <br />4. COWRY <br />g I 4mm oxs$oc KS f wham v.-.d x... iff...rrr. A.Y.. w�. - - - • .. ) <br />PTT <br />L � / <br />If i . 17- 3 <br />R CITY. TORM. OR LOCATION <br />C. LENGTH Or STAY w M <br />R QTY. 10001.00 UOCATIOH <br />Grand Island <br />Ienesaw <br />A "at of (if" to beep". ON eAw N/reM) <br />l STREET ADDRESS <br />'ramm on <br />Iutheren Hospital <br />Route 1 <br />t. 4 ILACE Of DEATH NMK cm UNIFS? TIES 010 <br />.. 6 Rti/OERt[ INSM CRY UNITS? TIES J. TARP RESIOErc[I its <br />10 M <br />1. "6" ew Mar AFiEN Low <br />E. DATE lfavM Dow Yen <br />sessAme ( Ramona Mlen Lockwood <br />KATO 4 20 1965 <br />fX <br />emale <br />i. RAES <br />at rem" <br />T. rARREO RtYER MARRIED <br />"nor am <br />S. A" ( pen <br />r uao i vulm <br />u m" as MeL <br />Aca,Wm D... <br />AI..- „`. <br />aroRCED <br />$ov.27 1928 <br />lroler) <br />USUAL OCCUPATION (OW Nd./Nrt ow <br />Iii. RMDOr WSRI[SS OR RIDOSTO, <br />11. BIRTHP ACE (Nde M)1MfI# tMAbs) <br />) . emu" or WHAT COU IRVI <br />n' ri��""re" <br />�11& <br />FarminH <br />St. Hlchaal Neire <br />U. S. 1. <br />FATHER'S RAF[ <br />f]Y.rOTMA'S IIARxR RAKE <br />N. HARE Or HUSBAND OR WIFE <br />John J. Hammerlinx <br />Oliva Fan Trump- <br />Do lama Lockwood <br />ST. WAS O[Ct_AYO EVER M Y.1 Amuce macro <br />It. SOCIAL SECORM "mI 17 MFMMARF .NArn/ <br />0 <br />x-30 ouHlaes Lookwood Kenesaw He1re <br />IS. DAYK N QDAYN (WWI wiF.w cover M I'm P• (•`, (0), RN (c).( <br />INTERVAL KTWEEPI <br />PART E KATR WAS CAUSED DT, <br />TM <br />mo!cmTt CWK (A) <br />Z <br />ef.ItAf Nf .R4r- Due TO (c) <br />erlRr cavef lw. <br />/ <br />PART" OnM SIWICMIT CDmnom CWMfDHI m TO DEATH DINT ROf RRATES TO TWC ?CROP" DDRAS[ Cp1W1 T10M GINA M PrIT 1(.) Is. <br />WAS <br />r <br />PERFORMED? <br />S <br />TIES ❑ no <br />Ms. ACCIDENT SIHCIOE IgMR:IDC <br />M. o[leRIDE HHOW HRJORr OCCUMI[D. IWw R.fY1 yM/HVr IR f'arf I.r welt !I e/ krn fr.) <br />C <br />y <br />❑ ❑ <br />Jk. THK Or Hear A1@%^. Der. Iffw <br />V <br />MUST 1. 1R. <br />a <br />,~ M• <br />ad Ru1MT oCCORRED :4. PLACE Of INJURY (r, r. 1R e/ ehP1Hf 4Hw, bJ. CRT. 7OWR, OII IOCATpR ODUR7Y STATE <br />WWR.E AT ❑ . _.�... <br />— <br />WON AT WORK <br />fl f a/NRded #Ae Iaaeeeal teem , b �'� Re)1Aef w W . /ha en d of <br />Death rdal of w e11 tA. /afa eNfal .l w.; .RI toe" &"#*Imv AMw N. Frain <br />tie n M I04) /T M AOORESS � .ne. <br />DATE S6&w D <br />�7 Ls��/ / <br />m <br />tae. CtMTISII <br />m. DATE <br />( de) <br />. DATE Sr fSTRAR <br />.� X26 � }_ <br />IS. REsgTMR Nil RE <br />b R[ Or HORT�AR J%_ <br />Y// 10('(�•jj+'/ r <br />Please index. ac.a.inst 28, <br />and the East Half c"f rn ^;o r*, -? ;, <,;;+- <br />(?uar.ter of Section 333, both Township 9 <br />'�crth, Pan-,e I Pwst. of the 6th <br />Ha i.1 :ounty, Nebraska. <br />i <br />7 <br />m <br />Aid <br />n. <br />