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STATE (IF NEHRASKA—DFIIARTNTENT 0F IWAIX11
<br />Hurva" ,f Vito, stati'liv,, 85— 005273
<br />C TIFICATE OF DEATH
<br />CEASED —[MME I.W t— SE, 1DAIL OF DEAlK
<br />I
<br />RACE
<br />RtRl-IO I wl DATE OF Dfff- 1-U-1 01 DEITO
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<br />► GRAN-o IsLAND
<br />YES VETERANS HOSPITAL
<br />SIFFIVE Of 9" 1 - viot MARIED , PIEVER 04ARoffo. ;SURVIVING SPOUSE I IF w-, C-1
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<br />W WED,D#VO4Cf0,wv-
<br />U.S.k. It FV.ARRIED % A NA (B E I NS I LL I AM S
<br />SOCIM Ifft"m Pilimm
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<br />1JSUAl OCCUMTipPJ 41w A . of FFAIll KIND OF WSIPIESS, OR tNOWWY
<br />507-01-55,07
<br />.m, "t. 'Isto.
<br />RETIRED MECHANIC AUTOMOTIVE
<br />cOUwv
<br />70*14, OR LOCATION I AND 0,11.0ho"
<br />:� cl.� 1-17. 1571"'t
<br />NEBRASXA
<br />%*.HALL
<br />lary,
<br />ISLAND 'If
<br />GRAND YES— 1. 419 E. SOUTH ST.
<br />'tWI`
<br />".7
<br />w N NAME , M41 —41,
<br />(DEC) HENRY
<br />WILLIAIeS
<br />ji4'OTh`RCL� 7EC ) JENNIE QUILLEN
<br />OWPOWPANT — NO-44E — 11CIA f 10 NS 0 W
<br />AtAk04G ADMESS IIM" CIIi ... . .0, LM M IfFFFFI. Mq, ;FFI
<br />4,19 SOUTH ST.. GRAND ISLAND, NE. 68601
<br />R.. ANNA REINS
<br />_�
<br />A7" WAS CAUSED SY; [FNTfR ONLY ONE CAUSE PER LINE FOR (,l, (ot AND jltl
<br />CARCINOMA OF LEFT LUNGIPRIMARY UNKVOWN 6 • ONTES
<br />M. G. I AM 10 (b)
<br />C...' FAA
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<br />CIA
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<br />##AT X. 0"Aft poN.TI'11NT COPMIK" CONDITIONS CONTIfIgUllIFIr 70 0W. SU7 .01 -tWtz
<br />IF 11FA0,Lt. ..b TOW
<br />TO CAU39 ClWm "Il FARE %Q
<br />Cl.. THE l.sl 3
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<br />INJURY OCCUIRAIED -I --lu" CIA
<br />OR UNWIPWARM I MCI" I,
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<br />noxy AT WORK
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<br />110CATION
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<br />A— Y— MF DEATH occijIvirto I
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<br />100972 1 ,,jJ U N E 19,1972l,,JuNE :rf
<br />CWTIwAlsom—iftDc" ExAmmeElt OR CORONER —6 L i L
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<br />1A.D. �23b.,�', ;,I , '- j V�'— 2
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<br />'i G*RANI!�; u"
<br />NEBRASKA 6--
<br />VA Ho TAL. 2201
<br />S—P i
<br />NORTH 0 WE L/. SLAND,
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<br />THIS cza?nqzs THE ABOVE TO BE A TRUE COPY OF AN ORIGMAL
<br />CBERTIFIr" ?E ON FILE WITH THE STATE DEPARTKENT OF HEALTH,
<br />Wlit,&U IiW VITAL STATISTICS, WFITCH IS THE LEGAL DEPOSITORY
<br />=R.Vl7FAL RECORDS.
<br />DIRECTOR OF VITAL STATISTICS AND ASSISTANT STATE REGlSTRAP
<br />LINCOLN, WESRASKA — Issued June 30,
<br />-I
<br />I
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