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STATE Of NfORAARA OkPART ENT Of HEAGTfo / „ � Q
<br />MUREAUOf'VITAt STATISM5
<br />CERTIFICATE OF DEATH EXHIBIT NF<N
<br />_C00T--NAW flfi$T MIDDLE LAST 3i N ,DAif I)f bE'kT3d IMw (?car, 1, ,
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<br />act . R B.Rk „ —, tk , ACE N EkR )NOER 1 PAYE
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<br />Ind .ER) Sp ,E,1 10 h j bP FYI Y os OA 5 -)URS MIN$
<br />Whitw r.;k.._ illil °r t( d,l ) )1) At 7 ''; (,1,. I a t P'%4
<br />iliY A I�' TAF OT bMTN (a -1-,. U S.a :CITIFEN OF WHAT COUNTRY I"WED, N(vep MARR u; iNAAaE T.JF &9AUSE 10 m,f., N • a• s,n •,
<br />n.R,. e.p,h Y iWIDOWED_Gt
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<br />SOCIAE SEfU�En'NUMRER iUSUAI ACCUPANON, Cirs. L,ndpf wp,i dpn. dr,v,ny mnrf ;KIND OF BUSINEhS OR IMDU$TRY COUNTY (i of AtN
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<br />12 507-14-0608-_ �;TQ t :du ctoi q l!.I'.k.1: N HaIi
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<br />E; TTY. TQWN @R IOC ATIEiAI OF DEATH 7lNSIDE Ci %LtMiTS r Nt75Pli AL 6R U(NER IFFS iIiJtIC -•N N.— ;ll nsr q •r,A•r $o OR N9 �d ,nw trt�•
<br />(s'—P, Y.r prN d ,.• f —b-
<br />Jo—grand Isl and
<br />RESIDENCE -STATE COUNTY !(,ITYro— oRtOCAFI N STREET ANDNU.1111 eM41DE (Iiv EIMM
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<br />ISw N�.k�r3 ka �ilb Ilan , t,F.m11 .<uTEi ud i 1 ', ,,. Rt.Ill�
<br />sue._ . M()FN(R Mwl(1FN NAME ri6�t . _..... MIDD'1 F. , .AST
<br />PATNERki�iNk` FifFSf_.� .MIODtE ... IA51
<br />WiIIl, St ki 11 t, far art °t_ -- LI
<br />WAS DECEASlD EVER IN U 5 ARMED fORC FS� INi(.RMA NF -NAME P.E:AZION SNrP MAIEIN ADOPT
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<br />IBYeS ],O- LA -_43 = L- 1.7 -i4 144 11 14 ^iadi•ne St tl .- '.v[tr -I1:: ti i.u[> (t'and l!,'.,J;I(i, ..1(. f t;Nfli
<br />._ - .. -. —. -__. .NAME .... !LOCATION_,.. CITYORTWM STAFk _...
<br />i -6UR1A 1. Crn align. Ramava{DATE CkME1ERY UR CRE MAIURT
<br />Aug. 21, 198,
<br />IAERAUAVfI iPURE/ F.�(N {ia .. btl IntEtNl M1iuN.MF t (II' Ili E ., i 1.23RFI,04'nJ I;1 1 t(I 1 .; ,
<br />zo. Burial �!1 /200 0 Y,ttir1 1 , 1 3P(. ( to L
<br />{ 4ro < [rt cP sxt r
<br />W_ ,l 22 2nd [,ruJU Is (Yand, tii 5880 1
<br />i E AT (Me ,,D.,, /R.j .DATE SIGNED IMe Doy, Yr , ,HOUR Gf 6EATN �-
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<br />127. 18.-'August 1'984
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<br />`OAiE PINNED FM... Dar. Yr./ �NOL/R Oi GEAirs - .. ^. PpgNOVNCFO DEAL ,PRONG. Q( C. DEADINO.,,r
<br />I� •FA 6 I E .M C:IY Y r
<br />v 216 August 198E 2h - Y 2 ) 1a
<br />i 4! .u..• J dam. ••e O ur a•e h ac�..d ur _.__
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<br />NAME AID ADDRESS OF CERTIFIA FPNYS&AN .-,)RONfR S YNPSICrAN G® COUNT) ATMRNEY
<br />ri — P-1;
<br />,111d vr.. 0880,
<br />,
<br />2s _ J. Lawton M ll. Ea= 1 _� .c °v , (1 : n(. l
<br />----
<br />.ATE REC IYFD BY fit C15E RAN Ma C Y - - ,
<br />-
<br />X27. IMMEDIATE CAUSE ..._ . -__..
<br />fFN7ER ONE Y ptvE CA 52 PER TINE FOR !o, r b, AND rr.' ,,,•nor t• .. o..,., nod dw.+.
<br />PART Acute card2.Orespirator'y' <31rc-SL
<br />I.1
<br />DUE TO OR AS A CONSEQUENCE OF - _ - _ - - r..,,,,pi E. .,,, ,,,.., a +d d•Wn
<br />.) Myocardial infarction
<br />DUE TO, OR AS A CONSEQUENCE Ui ,.Nnpl ..��,..� and d.o,�..
<br />- ._..__. _ _ wA5 [ASE RflFRRfO TO 14-61.A1-�- --
<br />PART OiMl� SIGN1iK AM CONQITIONS C.nO 'o ..w. ..p...�R 'o a.urn -b.r nland s•/1 III r rFM•11 WAS iNi �E A AUK)RSr.____ _- _ _ _
<br />RRlG NA NC Y IN (ME PAST J MOW,W p.. r, 1,< e, No. EKAMINEk 04 CGRONEp
<br />IE - tSw <,Fr, N
<br />Y., No '.. 78 NO '29
<br />-. ______.__..
<br />---- - -� - -- - -�- - -JOr r.; NOUR W IN.IURY ,OF Sf RIRF M(iW rNr URY 4CCUiRED
<br />ACCIDENT. SUKIOl, NUIWCIDE. UNpEf GATE W INIV4Y iMw
<br />0. PENGNG -"srlG tlON (3--f"
<br />I
<br />700-
<br />-- SP«,Er Yn « N.1 i .NM. A.gdi :MgRb .. N ; So•<dn . 30,
<br />ENU A/ wMR AE M
<br />30d STRE_ E
<br />T 01 P E N. C Y! OR 104'r -N 51.1E
<br />30f.
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT" OF. HEALTH, IT CERTIFIES THE ABOVE 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 RECIORD5 ,
<br />a. Il uud Auc. 28, 19811
<br />DIRECTOR, BUREAU OF VITAL STATISTICS LINCOLN', NEBRASKA
<br />L.
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