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STATE OF NEBRASKA— DEPARTMENT OF HEALTH
<br />Bureau of Vital Statistics �y
<br />CERTIFICATE OF DEATH //j,Eyye .... ........
<br />uccRAam —MAM/ run M.I. 1•fr SER
<br />DATE Of DEATH I rDmt., D. r, reu I
<br />I. &M Hcumo rFeni2le
<br />t OC&6e4 21 1977
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<br />COUNTY Of DEATH
<br />• a ,. 2 ,► 31 f 1905
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<br />C . i WN, OR l A DEATH I« w1 Cm Ilrrt{ HOSPITAL
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<br />OR OiMER IN3TIfUT10N —NAME r it 1«JI I« Err «I.. Glue SrMN
<br />I "C11• os ON «O
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<br />STA Ca NR1N 1 H nor Im u.,."., »•.! CITIZEN o/ WHAT OUNTAY MARRIED, NEVER MARRIED, SURVIVING SPOUSE I11 .UI. Glll rA1en1 mArf I
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<br />WI O, DIYOR 0.......
<br />1 Ne6 •. U. S. 14. lie �_ Pau,1 Hieronymus
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<br />SOCIAL SECURITI NUANfw USDA! OCCUPATION IOM a B or .Daa Do»l DWI «c tuft or KIND OF WSINf55 OR INDUSTRY
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<br />RtSWfIVCE_STATE COUNTY CifY, TOWN, OR toCATION wflel CITY Ilan STRE[I AND NUM R
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<br />1k Aand Leland ed 111. 103 6cwt Isaf/i S;tAeei
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<br />rlDOlf I.,t MOTHER — MAIDEN NAME rust 11 NII
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<br />te.WAS MCIASTO EVER IN U.S. ARMED FORCES? INPORMANI - NAME - RELATIONSHIP - MAILING ADDRESS
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<br />ART 1 DEATH WAS CAUSED ST. IENIER ONIY ONE CAUSE PER IINE POR f•J, fbf, AND Itg •,ra "^'` '« •,s
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<br />INJURY AT WORK [ -JURY .I wOw, r• {r, ,11N1, rMlgl, LOCATION I,ratn 01 1 r e ro , CIn ON to." n ll ,
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<br />- L444 F&Ldley Grand Igland Nebraska •' 68801
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<br />461KONSI, NO. REGISTfAf— SIGNATURE
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA 1
<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 O.F VITAL STATISTICS, WHICH
<br />IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DIRECTOR OF VITAL STATISTICS.AND ASSISTANT STATE REGISTRAR
<br />LINCOLN,NEBRASKA - Issued November 71 1977
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