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<br />F1'rst Addition to the City of
<br />----Lot Seven (7) in Block Nine (9) in Meves
<br />Grand Island, Hall County, Nebraska
<br />
<br />~
<br />.,~
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />STATE OF NEBRASKA--'-'- -,>
<br />~ "" ..... '-.. '\i:. \~ '" ' ,
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA [)EPA~li-''''T'P/f ttF.r'31- 1"11. AND
<br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COpy OIi::t'H&~tGlNAL 'frtOfiJflQ pN
<br />FILE WITH THE NEBRASKA DEPARTMENT OF HEAL TH AND HUMAN~E'kJ.V1t$I'\WM p€f:Qf(l?5' J
<br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS,:.:,- ,~/:.... '0 ~_. -.',. .~... '/~~:'~:._"'..'.'..
<br />
<br />DATE OF ISSUANCE ,.;': ;:; ., ~4,~"
<br />':'t :; $TA~ 'rlcJElR : " ;~,
<br />'" ~SlSTAN: STATe R'1C#9mA'k
<br />;'.. -.....J::l. 6PiJ~TMENT ORtlEA. OiuAl ND. .c,'
<br />'I <W,? 'Ii. . ,....J~~. ' 4io:I-' ~,9'
<br />(.!,~. '. ~lf(),~~; ;~'\ .;, f::' ,
<br />,II II V /- ..... ..' ,,\J....l ~
<br />~!II, - "Ul,W:~ ..:...;),
<br />\J~''"<'~;":_~~-::-l 062 t
<br />
<br />/.:: ,
<br />
<br />MAY 3 0 2008
<br />
<br />200804769
<br />
<br />I.
<br />
<br />NT . NAME
<br />
<br />FlAST
<br />
<br />STATE OF NDRASKA - DEPARTIIENT OF HEALTH
<br />IIURIAU Of VITAL STATISTICS _
<br />CERTIFICATE OF DEATH I '.'
<br />1,.\5T 2. sex
<br />
<br />MlDDU;
<br />
<br />
<br />I
<br />
<br />3 OATI! Of' DEATH ....... Olt'. y_
<br />
<br />Wilbur
<br />4. ClTYANOSTA OFIIRTH l"n"unV$-"._-,)
<br />
<br />Dalton Arehart
<br />llli. AGe " ....1IlftIIday
<br />(Vre I &b_ UOS. r
<br />74 :
<br />
<br />DAVS !Ie, l-IOUAS' ...,
<br />
<br />male Se tellber 16 1990
<br />. DATI! Of' 1llm4.--. . 1'_
<br />
<br />
<br />
<br />Huntle ~ Nebraska
<br />7. SOCIAl. SECURrTY I>IUM8ER
<br />
<br />June 15 1916
<br />
<br />50S 24 0220
<br />III FAClUTY . Heme
<br />
<br />~ ;II...... 0 ER.~ o !lOA
<br />.mtEB: 0 t.IurIiIlg HolM OJ ~ 0 '*- IS(>>cIIy!
<br />Ie ClTY. TOWN OR lOCATION OF IlEA TH 8d INIIOe CITY lMTS
<br />~ )'.., Of NO!
<br />Y
<br />
<br />Nebraska
<br />
<br />.Hall
<br />
<br />10. RACE "Ie-II-. _...... -." Indian. II. ANCI!STRV f..'........ _.~. ""_1
<br />...-ll~)
<br />white
<br />1.... USUAl.. occuPATION 1GIt/fI_1II_ _ du<>np _
<br />111-*"111". _,__ "
<br />Accountant/Owner O~
<br />'8. AT " NAME MIDOI.I1
<br />
<br />(dec.) Jesse Raymond
<br />18. 0 EVER IN U.8. AllrilEO ~0fIC118?
<br />rv-. no. or unIll (II.. give _ end d-.OI_I
<br />Yes WWlI/2-23-43/12-l-45
<br />20L !IUAIIoL. c..n.......1'IemovIII. 2011. OAT,.
<br />DonIIIon
<br />Burial
<br />21. ~. SlGNAT
<br />
<br />Me 1e Edna Clausen
<br />OI"I.fj).IrIO.ClTYO'n~. A 01
<br />
<br />Genevieve Arehart. 656 East Ashton. Grand Island.ME
<br />200. CRiE1'ERV OR CFll!MATOFlV " NAME liOol.l.OCATlON CITY OR TOMf Sf"""
<br />
<br />1123 w.
<br />
<br />Chronic obstructive lung disease
<br />ou.. TO. OR ASA ~Of',
<br />
<br />3-4 days
<br />.............. - --
<br />
<br />years
<br />-----
<br />
<br />
<br />. CclIldIIIono ~ Ie> .... bulllGl ,_
<br />'f'AIlT .
<br />· Cor pulmonale, chronicbrorlchi tis
<br />2k ACCIOENT. SUlClllE, HOIIIClOE. UNllET.. 2lJb. DATE OF INJURY IUo..o.y. Yr.) 2ec_ HOUR OF INJUAY
<br />OA PalIlING INVaITlGATION ~)
<br />
<br />a. WMCAII....lO~
<br />~ ()lII 00l0ilER'>
<br />/StI<<:JIy 1''' ., NO/
<br />
<br />lilt. IflJURV AT WOAK
<br />/Spet:JI; y.. or NO/
<br />
<br />STAEf'T OA Fl,F,O. NO_
<br />
<br />ClT'i 01' TC:lWIt
<br />
<br />STATE
<br />
<br />2lllI_ OATE SlGNI;O 1Uo. o.y. 1',,)
<br />
<br />2Ib, 'flUE Of' OEATH
<br />
<br />alii, DEAD /HIIt6I
<br />
<br />-Y-
<br />
<br />ONO
<br />
<br />o UNI(NOWN
<br />
<br />o VES
<br />
<br />D. WAS COHSllNT GIWfTED?
<br />DYES
<br />
<br />ONO
<br />
<br />31_ NAI,ll! Ar<<l A~S$ OF CERTIFIER (PHVSlCAN. COAONl!R'S PHVSlCAN 011 COUNTY ATTOIINfY) /TYIi>> or """II
<br />Leticia M. Pinto. M.D.. VA Medical Center, 2201 N. Broadwell. Grand" Island. HE 68803
<br />
<br />3:,11-
<br />
<br />
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