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<br />1111 N. Eddy St. ... . v-liJ ItCD
<br />[JWlOOWEO [3 _OfSl'OUllE 111____
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<br />l---9- V[S 0 NO . [[] UNKNOWN I ~ 0 ~~~_ 00 ':'.'-__ 0 YES [jJ 'OQ
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<br />I __ _ La!,>, Han: M.D., 3016 W. FaI.ley Ave. G".. "'an., N"'......-..
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<br />
<br />STATE OF NEBRASKA
<br />
<br />I, OECEOOIT. NAME
<br />
<br />
<br />I. aT; AND STA,", OF lIlRlH
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSTIC$~rK}"f1y""!JjICH IS
<br />
<br />::::::~:::::;TORY FOR VITAL RECOROS;Vb1'iJigiii;-j,
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<br />',",'E,P,' 1, I.,' /,'_r1I,l,;' ;20080363 '; JV~"vftTAN~~SLCobPEfl
<br />;) ASSISTANT cSTATEBEGJSTRAR
<br />LINCOLN, NEBRASKA HEALTH ANDHUMANSERt/ICES
<br />ST....11!OFNEBll.ASKA-DIlPAl.D&NTOfIlW.1HANDIIUMAH_YU!lRNAMcI!.~_ _',,' ',= "
<br />CER";;~nlo:..~1H Cc, ::~:c--o-"~~::;!-r'~29
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<br />lAST 290
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<br />fIRST
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<br />1.0_
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<br />Paule
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<br />Helen
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<br />.- 1 YEAoII
<br />50 lIOS OIIYS
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<br />17 .MS
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<br />o Olho< _.,
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<br />Danverke, Nebraska
<br />
<br />7. SOCIAL SECuflnv I<IJIAllEIl
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<br />.., PLACE r:w OfATH
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<br />DOOA
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<br />505-20--6708
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<br />1110 "'lllIlE CITY LMTS ",.. COUNTY Of DeATH
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<br />Beverly Healtb Care--Parkplace NuniDg BODle
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<br />1<. CITY T~ OR lOCATIOfl Of DEATH
<br />
<br />iIaIII
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<br />Grand Island
<br />
<br />
<br />Madeaa
<br />
<br />Illll COUNTY
<br />Nebraska 1_ Hall
<br />110, :~~~ --- w"::>vjoO" " =~~"':j... -, ".<an ~...,
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<br />'... uSUAl OCCUPATION 1~.ind"''''''''_<lP>flmo>l
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<br />Waitress
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<br />FlIlSr
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<br />Nicbolas
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<br />Nels
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<br />ADU
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<br />18, WAS OECEA$E[) EVER IN U,~, _0 FQIlCES?
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<br />lIAII.tIfG AOOIlEl;S
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<br />15T"IOHOORFC; ..o,CfT'ORTOW1'< STATE Zlf'I
<br />
<br />Robert Layher
<br />
<br />P.o. Box 69, Elba, Neb....ka 68835-186\
<br />
<br />1~"Uro \iE1I1OOOFDl9OSl1'~ ! ~lb OAl"f 7ft: Cf_TEA'V~""'l~ ....
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<br />#1071 Iljj_ OflOmo,.1 LOctober~1OO1 i Wesda...~
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<br />All Faith. Funeral Home 0 Ctto_ 0 ~ l~ Gralld Island, NebnIb
<br />m <ur.eRAl HOME .oo<1ESS ISTREET OR RF,O. NO Cltv OR TOWN SlATEllPl
<br />
<br />2929 S. Locust St. Grand Island. Nebraska 688GI
<br />
<br />2'J _OlATE C.USE
<br />P41lT
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<br />IENTER ~y ONE CAUSE. Pf-R UNE ~OR 1,11' rbllAHQ letol
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<br />20 YRS
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<br />_ CHF
<br />DuE TO OR AS A COHS€OlJE!'lCE ~
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<br />30 YRS
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