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STATE OF NEBRASKA - DEPARTMENT OF 11EAL'm
<br />RIFIC of Vita) JlrPinJeRR 85_�- 001287
<br />CERTIFICATE OF DEATH IGA/lV[
<br />k E «,oau 7. ECEASED -NAM SEE DATE Of DEATH sr.a ns r
<br />wrr
<br />I -Dw, Fuo.v
<br />Geor a Warren Aforris r f4ale , 3- 10 -77» r•r
<br />RACE rqu1, « /clo, •wat•« I «ou« AGE - -1. u «wr I Dir I
<br />n< I ]purr r . !.«�. .rLU »oi r o.n V.oun�i DA1E O! BIRTH I ,.w.rw. on, tCOUNTY OE DEATH
<br />Wh. o .e.n
<br />'• N +, 1 -9 -05 I„ Hall
<br />CtM1, TOWN, OR LOCATION Of MAT" : «sro! c,n lu,rn rtOSNTAt OR OTHER RvStl(UTION -NAME II
<br />sreun m o1 »o r «or I» urea. en1 unu . «o «uw1. I
<br />n. Grand Ysland, Nebr. ,, des :t, Home - 915 W. 1st.
<br />NRTN 1 rr was « u CITIZEN OF WHAT CUUtRJDOB fiebr. Harried — �„ 2Ia i:ath n Scott
<br />E USA
<br />SOCIAL SFCt�1iv PA1Wf! U At OCCUIPAfION Ie:w two or wen owe owrwe .o]r or 1. -__ __-__
<br />-4 Lot. M. r, uutlD r RIND OF BUSINESS OR INDUSTRY
<br />11506 09 6263 Ret. Pharmaciat �{
<br />KSIDENCE -SEArt COUNTY II► _Pharmacy
<br />CITY, TOWN, OR LOCATION I «uo1 t:n ,,,, ,� STREET AND NUM{EN
<br />i4 :debt :INC:,r ref o1 «oI
<br />w hall k Grand Island ,, yes �,,, 915 W. 1st.
<br />fuP�t -NAIVE am
<br />wrDD1T 1•,r MOTNft— MAIDEN NAM( 1-1 rIDON
<br />Wilbert --
<br />f1e Y3 fwa ,..5 . D« E s_E,xrSr. o S;L C•FR alr enw:rrl DI10rr]S f'
<br />IN a a , Edna
<br />t -
<br />Ketchum
<br />-1 {tr.cgfr �h
<br />m
<br />-1 ' to IISNN-MARINO ADDRESS o1 t r o «o ur• oA ro
<br />.ART I Mary Misfdife,
<br />lr I
<br />915 W. 1st.St.Grand Island Nebr.
<br />DEAM WAS CAUSED {7 iENrER ON, Y ONE CAUSt !ft twt FOR
<br />H ««lDUN t.use —. IDI. IDI. AND (<ll rrn.11« or-i(yf ///P�,l ..ro oT +r«
<br />EkT'r�6�i Ta��rf'PwP "S�� P M �F = ,
<br />]r• a r «e c/roi�' I ow ro of f • co «NO lrcr w
<br />DT Et S+G,MlKANI COfgl/ffiPS1 CONgT1rWS CONTRIBUTING TO OEM. BUf NOr tl,Atfo PART Ii It /FMAIl. wAl Te(!F b AUTOPSY TO ALEl GfYEN tN It YES wlrl DIwGf (Dw
<br />_ _ /fPC.«•rrCY IN fn! PAST ) NINSI 1. r1I G »OI I flDafO Iwpfr Iw «,«G t•VSt
<br />C O, Dt•
<br />A tot SLKmt. A IN Y oA•, r •r Y(.�N... -D
<br />OR RASRrrfD rsrec«f,•�
<br />'Now INIUtr OCCURRED : e »NI «.ruu
<br />FOP
<br />r : or ul ne« u
<br />INAAY AT WOtK PLACE OF MAMY rr ntTw, rrW, ]rptr, r•Cr(HT M �1W
<br />1rK:n ns 1carrt — nc , I i LOCATION s n r r r o «o . nn o1 row «, u•n I
<br />:ERTg1CATKA+1-
<br />Pn•SK,AN. ws..,« o•. rru .o.rn. or. .r.1 � •wo ufr f•w rr,rv,.a M:w or. ow,olo .rot v�fw rwt
<br />A,•f «DI9 rw• PO � � «than D•r rr•I IOpr PR 01•r« ° ter. oeeuneD .r rwl tool. O« rw1
<br />CfRTYt$AtIOl1_` 17I, 11
<br />- MEDKAt ERAAYIVER Of C 1 0« `� 11
<br />P•w «....r°®n O. 1M IODr uM�Dt iM Mvtf le(•Iq,r. �w r r.l�f Or r:r1 nOU. °r or Mn P DKIDf f fofr4y.g10 DI•D I'n �� ifr- �u)I:f ar•ND
<br />�,+r occwnlo w Dn ow ro rm t•,rN:]r unto °r «ro «, i .c «r. r1•R ..our
<br />Ctli- NAMErn,
<br />DI4NAPyR M
<br />C•D• :•"d'ir3tfl �I rJ
<br />4.1
<br />TOAif SiONEO - P
<br />-4RK' ACDlSS CERfaHB f n1 o F- 4 r o�? rk 7 / Cf
<br />729 N r
<br />{tRdAl, CREAMTION, gypv►t CfMliFRY O! CREMATORY -NAMF n T G
<br />• IOCAnCAE cm c/ row« vur
<br />,, lsurial Grand Island Cemetcr
<br />DATE 1tfo«,� �-/p• _ Grand Island, ;1ebr.
<br />3 - +� -1 ! T. rlrl, {UNeRAt NOME -rYAME ANO ADORES$ f91N1 Ot r r 01 r o o trt• m rnww I
<br />l` -/ J>(1nfc1 -U - Grand Island, :debt. 68F01
<br />! EM{A(MER NACU! IIr��r
<br />73ff `} ir.SE NO RlG,STRAR - jIGNArUR
<br />�(}�.t�/j/ .,! / ///�/ •i! t! IO 1• ICKAI tt41]tf Af
<br />WHEN TAls COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />STATE,D'EPARTMENT 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 />IS•TRE -LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />=J= vR OF VITAL STATISTICS AND ASSISTANT STATE KLUISTRAR
<br />LINCOLN, NEBRASKA Issued March 23, 1977
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