|
i
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS `
<br />CERTIFICATE OF DEATH — $5. 00155
<br />rDECFDFNi -NAME — ._._-- -flt5t —__._ - .. - -.__—
<br />MIDDLE UST SEII DALE OF DEATH IMn Dv,. Y.
<br />LHUR -AT BEVERSDORF i, MALE AJAR 23 7983 -
<br />RACE -(e.g whn•, plerY Am•nr° CMIIG °n Df SCENT(• '- - — r ]
<br />O 9.0 1' n, M.a ton, AGE -ln.rR nae UNDEF I YEAR' lUNDF! 1 DAY DATE Of BIRTH (MO O T Tr i-
<br />d l A11 r 'I {F•1/S.�PL�•yrL��rl[,l I /Y.s DAY$ HOURS : MINS
<br />City AND S7ATE Of eItTN (N nor rn Uff MER CIT 7(N OF WHAT I _
<br />°e Z"-- 16 - - -- _ 7 OCT _ 29
<br />COUNTRYJ=JED. NEVER MARRIED, a- -� 9�6 _
<br />no 1. / WIDOW NAME O! SPOUSE", .,l•, fl,v. --- ^v,n•1
<br />e STn n�IBORY NEBR. Iv USA ED.oIYOlCfD(sP.rdr;
<br />soaALSfcuuTNUNeER WSUAL CKCUPATION/C..rkmdd°n.dl0 1�1ARRIED _III SA_DIE HOSTLER
<br />Iv /.°r[•n I, 1, n r(.ehr.d/
<br />91 KINOOF BUSINESS OR INDUSTRY -7COUNTY OF DEA1H
<br />17.507-48 -7095 „o F�R_I- j �I,b FARMING l,e _ DOUGLAS _
<br />CITY. TOWN OR LOCATION OF DEATH INSIDE HO iNiAL OR OTHEf INSTITU iION- Nome ((f oot rn •rrh.r. II NOSP "'HIT Md�roN WA
<br />OMAHA (sr.rdT Y.I., Ne) 19'..,rr..f end o Ewe, sn «1„
<br />= L YES __1„d CLARKS(�f>l HOSPITA_L____ I _INPATIENT r
<br />RESIDENCE - STATE — O-- - - - - --
<br />(COUNT' (CITY TOWNORLOCATION TS_1 EETANONUM ER —14. - -T- --- - --
<br />Ise. NEBRASKA ',uHALL INSIDECITY LIMITS
<br />3 GRAND ISLAND _ sd RT. 1 BOX 290 �"'gip " °' " °'
<br />MIDDLE �..RT. I�
<br />`LAST MOTHER -MAIDEN NAME FIRST MIDDLE -
<br />M,L y LASE _
<br />' AX ___BEYERSDORF ELIZA
<br />WAS DECEASED EVER IN U f ARMED FORCES? INEOfMANT- NAME- 'REIATIONSH /P - ZUEHLKE
<br />g..e .e. one oar« o .. .. MAILING ADDRESS ISIPEFE OR [ I D NO: [r f�'rpy�Q., N yTw(E�bTj
<br />U NO i el 9 SADIE BEYERSDORF IU�E, RT 1 B N�E�(b7RT AND-
<br />71
<br />i
<br />BURIAL. C.amonon, Remewl'DAT 'CEMETERY OR CIEMATORY- NAM '�- -°-'- �a-- �v- a+TD- ISSL
<br />LOCATION CITYORTOWN STATE
<br />BURIAL 70 b MAR. bi J9837or WEST LAWN MEMORIAL PARK I7od
<br />EM LMER -S NAIV { U^C SE NO 3 S 0 fUNERA . -Q9M . ISA. ND
<br />NEB9
<br />CITY OR TOWN STATE flf) �
<br />71.
<br />APFEL- BUTLER- GEODES 1123 W. 2nd GRAND ISLAN0j NE.
<br />T Of DE TH A[.., Oar. Tr.) T GATE $IGNEO (Mo Dvr. Yr /
<br />ID<. HOUR Of MAEH
<br />t>o. !1a7 23. 1ST93 :
<br />_ DATE SIGNED (Me., D.,, r. / MOUt Of DEATH ""O 7do 7Ab
<br />- PRONOUNCED DEAD -- TpfpNOUNCED DEAD (H..,)
<br />M
<br />73b. 3 -2q -�3 �73 ?:Sr encl (Me.D.,.Yr)
<br />fg t. rIr• ►•q N w, Yw•wledg•, .enY «rwM or rM e
<br />i £ r•.n•lal abM — '1/( OeN YQ a ea• ana d.� � -M
<br />in = Op 7Ar I lid
<br />ob
<br />Q. rna bwN al .aew,n« ° ndleb M• .o °r� on dee rr•d w
<br />• m. der• ena vlw•�•.d °a.e ra ° n, r• « <.
<br />° i7A• rs.v end r,rr 1� • ..o
<br />INETI f f,p• oerP.•nr) - ---
<br />EI ^
<br />DATE RECFI:c W REGISTRAR (� f
<br />i,,b MARL 2 9 1933
<br />( )1 gel b.r..,n a ^.w •nd e..r3
<br />"N�el b.nwen enra ene e.eM
<br />nr•nei b•Mew and o.•M
<br />HI onbr
<br />PAST N R SrRNNKANI CONpItgNS- Cend,•:ewr renrnb.Uwg w d•ellr bvr n•r ,•Isr•d fAll lllly 1 .[Nil! iN[[! •TA j-
<br />II EtlO WNCE lry IH[ PAST I U O•S• TwiS CASf RE[E[E[Np TO r[DIUI
<br />MONiN57 I I Sp•..I, T•r w Ne) fcAMIN[R CM COfOHER
<br />YRY �: Ne _i 1179 «.if t•r w Nel
<br />ACCIq M. StNGq. HO•YGiq, uNgI, ! DALE Of rfrlyR• IMe. Def. [. I HOUR a INIURY
<br />Of PErypND INYlSTIOATpry ISe.r.EYI D[SC RIf! MOW INIUtY OCCUff Fp
<br />I aoe- wb I301. _
<br />M.IUtT At WORR PAC[ Of IN,Ufi_ Ar Mr. I�rw. n.•w. 1• M 170d.
<br />/3p«d, Tw w N.I NIN• Y.,rd�n.. w. Is—o" T' lOCA1pH SIRRFT - --
<br />CITY OR (OWN STATf
<br />RFCCRGERS 1;�E�;�O: rte%( -
<br />WHEN THIS "DOPY CARRIES THE RAISED SEAL OF THE NEBRA zKR#-otDeeds
<br />STAT•£ DEPARTMENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br />A TRUE COPY OF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />DEPART.IENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH
<br />IS THE LEGAL DEPOSITORY FOR !'ITAL RECORDS.
<br />A..a__ te,
<br />DIRECTO$;OF VITAL °TATISTICS AND A _
<br />ASSISTANT STATE a REGISTRAR
<br />LINCOLN, NEBRASKA issued April 7 1983
<br />L.,
<br />I
<br />
|