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<br />K STATE OF NEBRASKA— DEPARTMENT OF HEALTH
<br />85-001097 BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />Ep -NAME FIRST iilDblE UST SE% OAiE OF DEATH
<br />_T. rtx/AR 1. "!l l,rVN0LP_g 7. ! Iaee ,. !I(Ul 21
<br />RACE - Will.. Whip., BIuM, AI..,I— ORIGIN /pESCENT(..g.,loollon.MS\k.n, AGE -Law RinbtloY UNDER 1 YEAH UNDER 1 OAY
<br />Dion, • (Sp ifw) Grown, ek.l (Sp.E:lwl
<br />�t+ (YnJ MOS. DAYS HOURS MINS
<br />6b. bc.
<br />�. Ahq ATE Of BIRTH ( not in U.S.A.. CITREN OF WHAT COUNTRY MARRIED, NEVER MARRIED, NAME OF SPOUSE (H.
<br />swR•SeVMry) V ( r WIDQW."'L)IVOIfC ED(Sp.rilY)
<br />R ,ectu)vsek, /:e(Tta -ska 1.S.t. Ig,,irvtttea ,,. rta)tce.5
<br />SOCML SECURITY NUMBER USUAL OCCUPATION (Giv. kind of wr4 dons during ono KIND Of BUSINESS OR INDUSTRY COUNT
<br />o(rror in I h, w. I rohro )
<br />M 51JG- 09 -SE30 ,,, !�,�c';y, r4itn�( ;� 7•s.Fa�(d Tiltnitce,;.'Penae/(a� Lol�lts I.n.li
<br />CITY TOWN OR IOCATION Of DE AT
<br />78 5812
<br />T, Dow. Yr.)
<br />1973
<br />DATE Of BIRTH (Mo., Day,
<br />YJtole 5. 1904
<br />• l T p J AX INSIDE CITY LI)MTS HOSPITAL OR OTHER INSTITUTION- NO•..(if not in.ither, IFHOSP
<br />�1iEaliCi l ai l.ait(i (Spur Y.t er No) Rir. 1n.M d h.r) Ovtp.r:i
<br />T 14c ! Ch ud. Cit•u(L tout ((ors L.taF� 14.. I
<br />RESPIENCE -STATE COUNTY CITY, TOWN OR LOCATION STREET AND NUMBER
<br />1Jeb.,t".'a 1Se. ((aC.0 1st. rrLQJi <j I/5i'mul ISd. 2105 N. Lou.L6e
<br />NAM 1 MIDpI (AST MOTHER - MAIDEN NAME FIRST A
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<br />MST. IMker.
<br />Ron. I.p.h
<br />atiozat
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<br />LUUTS
<br />er No)
<br />WAS DECEASED EVER IN U.S. ARMED FORCEST
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<br />ULLA CLn
<br />INFORMANT -NAME- REEATIONSHIP -- MAILING ADDRESS (STREET 010 F D. NO.. CITY?, I?!71 STATE. ZIP)
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<br />„`t s. Ftmtcc.s 1;er!uo,Pds -u •c -2105 0. Lou.use- se I seawd IX
<br />BU MALCREMAl10N,REMOVAI DAT,Eat 2 %
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<br />CEMETERY OR CREMATORY -NAME IOCATION CITY OR TOWN STATE
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<br />„oR uttltdat ; 197`
<br />,a Gha,(d 7s.Ca)Id Ceme.te)()r 70,. :ta(ut IsFct►td, 1.ebtcrsl�a
<br />R- SfGNATURE L LICENSE N_ O. _ j
<br />iUNERAI HOME - NAME AND ADDRESS (STREET OR R 1D. NO.. Con d EOWN, STATE, ElP,
<br />,�; ?rE�-:luttXL'A- Geddes 1123 u. 2x1t, Gna)id I,s.Cand, /!r 63301
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<br />�t NED(Mo..
<br />DoY• Yr.) HOUR
<br />OF DEATH
<br />MJ
<br />nb. 78
<br />i�3
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<br />E� PROFrOUNCEDDEAO(Me..Dow. Y,I P*ONOUNCEDDfAO(Nevi) u2.0 YRONOUNCEDDEAD /RONOUNCEDDEAD(Nom)
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<br />ai • �. /• L478
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<br />73.. 4tft M Tad. 74
<br />NAME AN 5 ClInd Iff r.Nrtlf EAU frl.frue.•c .wc•� ... ten.... ...,.... _ M
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<br />/7 - & 4��/ - - -- •-••' _..._ •••• � In• /met b__ enrw wM don*
<br />10, AS A SEQUENCE OF: Inwrwl
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<br />DUE TO, M AS A CONSOEENCE Of U ti C.mJOw ewM dM..M _
<br />7 tnbrml b.M.n .n... and tl.eM
<br />`N.HEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />STATE DEPARTMENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br />'A TRUE COPY OF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />DEPARTMENT. OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH
<br />ISr °TH,4; LEGAL DEPOSITORY FOOR/�� VITAL RECORDS.
<br />DIRECTOR OF VITAL STATISTICS AND ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA — Issued January l8, 1979
<br />Lon L
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