|
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL TH AND
<br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON
<br />FILE WITH THE NEBRASKA DEPARTMENT OF HEAL TH AND HUMAN SERVICES, VITAL RECORDS
<br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~ J, 1_____ u
<br />
<br />DATE OF ISSUANCE LJ ~
<br />9 2 2 STANLEY COOPER
<br />APR 1 5 2008 20080 3 ;~ ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEAL TH AND
<br />LINCOLN, NEBRASKA HUMAN SERVICES
<br />
<br />C~ NT._
<br />
<br />STA1EOFNEIIWKA..DlPAIlnalNJ'OF=:A~~SIlItVK1lSFDWJl1! 4MDO 3 06952
<br />CER11FICA 1E OF DBA TH
<br />FlR$T ~ODI.~ > SE~ 3. DATE OOlIl,"''''' - 0<Ir _
<br />
<br />Edmond
<br />'D. WAS DEl%ASED EVER 'R US. _D FDflCeS'?
<br />IV... O1<l. or unIll I I.... __""_"_1
<br />no
<br />1111> IRFOIlUART IWlJNG AfIDRl;SS
<br />
<br />
<br />1938
<br />
<br />Linda
<br />.. CITY AIClSTATE OF 81RlH """'''U5..__,
<br />
<br />Grand Island. Nebraska
<br />7 SOCIAL HCU!lT:Y ~R
<br />
<br />506-40-1331
<br />.., FAClUTY._
<br />
<br />~~
<br />
<br />~R 0 "'-9-
<br />~-
<br />o aooo.,_.
<br />
<br />11______
<br />
<br />3180 South Blaine
<br />B.;: CITy T~OPILOCAT~OFOEATH
<br />
<br />Grand Island
<br />110 AESIIlENCf:. STATE
<br />
<br />900 ~an.u.TS
<br />-1iJ....O
<br />
<br />Nebraska
<br />10 RAC~ -....~ 8'ac1l.A~W).an
<br />
<br />II:IlSoocIlwI White
<br />
<br />... USUALQCCIIPATNlt.I 'u-_d____
<br />d___~_'
<br />. .Bookkeeper
<br />"... ,:...THGR,~ NAIC 'FAST
<br />
<br />Bill Baasch
<br />
<br />c...-
<br />~1'1"'0I":..1
<br />
<br />~R~
<br />
<br />Reinecke
<br />
<br />_.'.f:_ .~', ~
<br />
<br />". c'~ ,~'
<br />
<br />
<br />3180 South Blaine Street Grand T~land Nebraska 68801
<br />1". ME:TtoIObOFDtSPOSITIOt'.I 21b OATE 11c: CfIWlE'!RYOflCRfNl~TOR'Y III".
<br />
<br />rn ........- D ......". June 14 2003 Grand Island Cemetery
<br />21d CE'UETERYM CAEMAtoAv LOC'ATtON e!l'( 0Fl TOWN STAU:
<br />
<br />A fel-Butler-Geddes D~ 0""",,"'" Grand Island. Nebraska
<br />M ~UNE~.-.oMS ADDRESS t$T"I.:ii:rOfilril,F,D tro cn.v OR TOWN, STA1E.lIPI ..........i....~__.----...........__~.
<br />
<br />""~r
<br />
<br />1123 West Second Street Grand Island Nebraska 68801
<br />23 IMWEtMTE ~USf /ENU:A ONL Y ~e: CAlJ5f peR liNE fOR tal 'Dj, A~O (Cll
<br />P~AT rnu./ +i-..s l..(.5k.rn G..J1...A-rC-
<br />'"
<br />DuRO' OR AS'" CORSEO~E..ee 01'
<br />Ib' rroqrc....sS11lc. S IAiX!of+iQal..
<br />f TO. 01< OS 0 CORstOUERCE OF
<br />
<br />tftItrval ta8twNft ~,.., 1JUtI,
<br />appro~" :2 u..>of!€t:s
<br />
<br />IrWIIrwlll ~onIet.,...aMMf1
<br />
<br />de m~ T'I h" a...
<br />
<br />:eipProy. 5 l.fe4l" 5
<br />
<br />~....al beMIen OI'IM' 1"0 dt....
<br />
<br />1<1
<br />OT~J;l ~ICANt CONDtllOtllS. . CondiIlOM eoNt'~~ ~ DNtt'l bUll'td:'~
<br />P~RO OJ" 0 I h'-fperkns; ,'on, 'I-fl'1ro'-d a /s ettS~
<br />
<br />
<br />PAf;::T II! j~ ~E.UA.lE. WM:. T...e.RE: A 12~ "Ul0PS~" :2; w.~ i,.lL2.e. RE:.FEAREO- TOMEOlCAl.
<br />PRtG",.NCv It.! THE P4~t J. "'O~"HS" I E:x.UlNEA OFt CC-+<lNtA")
<br />1"90"~2. V.. 0 1;" ~1~I;C Yo> 0 ...~
<br />"'" jl!&> DATE Of lRJullY "'" VOr Yr.) >6< HOUR OF IRjURY ru;, DE%RIlIf. ><OW IRJ"~' OCCURRED
<br />
<br />o At,...adent 0 U""lm~ I t.4 (
<br />
<br />o Su.c1C)! 0 Pei~ 25e INJURy AT WORK . 281 ~;~~J~~Y .(ti.-.~ 1.6""1 !il.eel tacll)"y 126g LOCATION
<br />o H()I'nItIdi In"~'uo.a'tO" "-" D No 0 J
<br />
<br />127. O;.TE.OFDE;.'H /1\40 Da., ~rJ I 210\ [~.6.1ESIGNEO fAN> Oill' "'rl" i~ r"'EOF DeATi-'r ~~-
<br />
<br />,,~JunelO.2003 ----.d,.~~1 I ..
<br />
<br />I r ~ 270 DATE SlGRf.D (Me D4r y" 270 T1t,lE Of Oe"M ! j ~ ~ ~ 28< PHOROuI;CEO O~oO .,," ll... ,,, 28d I'llO'<OUN~,D ""00 ,.....'
<br />
<br />~ f~ 270 l~:!?;: 2 a:: 3 M ~ j ~ ~ 21.,). ,.. _... .,.~.",'''..'' .. -~.~'::"'Y ..._ oo.~ om.... ~ M
<br />
<br />"'.....,_. I. ~..""',"~."''''''''''''~''''''''''.!'_''_
<br />_-..l:..I!Iog~..I'\d-T,t\eI.
<br />O~ATt1~ "'flON 8EfN CON8ItiEREO" , 30 b W~S CONSENT GfU.Nif,O..
<br />o UR'Rt:lWN ~ N(, I 0 YES
<br />31 RAME AND AODRESS OF CERTlFIEf; IPHY5IC;AR, CORORER S PHYSlCIAR OR COURB ATTORNfr '",.or PMI'
<br />
<br />STRfE'I n~RF 0 ~
<br />
<br />>";'11 '( OR 'eMf"'-
<br />
<br />S1A.ft
<br />
<br />~t;O
<br />
<br />Steve Husen
<br />32. REGlSTAAA
<br />
<br />
<br />GrandpIsland. NE 68803
<br />:';, DA.HILEo:.JrfNTl {) 2003
<br />
|