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<br />~', . <br /> <br />Rev. 1/94 <br /> <br />STATE OF NEBRASKA - DEPARTMENT Of HIA&.TH <br />IURL\U OF VITAL stAn8nCS <br />CERTIFICATE OF DEATH <br /> <br />200808466. <br /> <br />1. DEe! . NAME <br /> <br /> <br />LAST <br /> <br />2. SEX <br /> <br />3. DATE OF DEATH 1_ Day. YNIj <br />December 3, 1996 <br />8. DATEOFIIl~ """"'f1<Iy. YII/ <br />February ;1.9, 1922 <br /> <br />FIFlST <br />Wayne <br /> <br />4. CrN ANDSTIlTE OF 8lllTHllflWlti/ U.S.A. _COUffIty/ <br />Burton. Nebraska <br /> <br />I <br />~ <br />u <br />~ <br />':l <br />O. <br />u <br />15 <br />! <br /> <br />'1 <br />..1 <br />t'.'~ <br />'.O!ij <br />u <br /> <br />~~ <br />LL D- <br />o!' <br />~~ <br />z~ <br />~ <br /> <br /> <br />(lfflrlt........ tivrI- <<rdNmbll1 <br /> <br />Ia. PLIlCiOFDEATH <br />~ O.ln__ <br />OER'~ <br />000\ <br /> <br />~ I!J N.....g H_ <br />ORN- <br /> <br />D 0tIlar IBpGdyI <br /> <br />Grand Island <br />Ila RE Ii . STATE <br />Nebraska <br /> <br />ER ~ZIIIc..,68883 g",INSIDtClTVU ITS <br />BUIWick. Rd., v.. D ....0 <br />o wtIJClWl;:D 13. NAME OF III'QUSE 1II_.g/""__1 <br />DIVORCED Julia Fotinos <br /> <br /> <br />III "'It.g., Wl*.1..k. Amoricln nIIan. <br />"'.1 (8ploutlv1 Whi te <br /> <br />,..... US\JALOCCUPllnON (Give Ir/rtdot_ -1irif(I- <br />oI~", _1I-.r1/ <br />Fanner <br />FIfI8T MIDDLE <br /> <br />CoIoQo 41.4 qr 5" <br /> <br />MAIIIEN SURNAME <br /> <br />NMN <br /> <br />NMN <br />; , Is Veterans IIane <br />Grard Is1an:1, NE 68803 <br /> <br />5677 S. Burwick Rd.. Wood River. Nebraska 68883 <br />1<10. Of 211>. DAn: <br /> <br /> <br />Qg Ill. 0.......... <br /> <br />00..-0- <br />. STATE,ZIPI <br /> <br />ls1a~d. Nebraska 68801 <br />1...1 ONl. V ON! CAlJ8E Pill LHl F I~ IbL NW (ell <br /> <br /> <br />Park <br />"Ale <br />Grand Island. Nebraska <br /> <br />inri",", bolwftn <riM! ond _ <br /> <br />Failure <br /> <br />3 Weeks <br />, _ol__..ddoalh <br /> <br />I ..,.. _ ......w_ <br />I <br />I <br />I <br />:IS. WAS CASE _eARED TO MEtlICAl. <br />EXAMlNtR OI'lCOllONal? <br />Y.. ..... <br /> <br />O-OU_ <br />o Sulclde 0 "-'dint <br />0- '_OOb <br /> <br />.. INJURY AT WOIIK <br />y..D NoD <br /> <br />8Tl\l!ET 0fI flF.D. NO. <br /> <br />CITY OR TOWN <br /> <br />STATE <br /> <br />lI7J. DA OF DEATH {MD.. 0.,;, l'r~ <br /> <br />liD 1MtJ. 1.101' YrJ <br /> <br />_ TTMIHJFOEATH <br /> <br /> <br />i I ! i IlIo. PPloNouNcEll DEAQ /MO.. ~ YrJ 28d. PfIOHOUNCBlIlEAll (JtwiJ <br /> <br /> <br />~ il _ On"'_oI_ln-._..IIMIlIgIllor1.ln~opInlon__.. <br />~ Ii Iho ti... _ MIl pllooo ond _10.........01_ <br /> <br />T <br /> <br />M <br /> <br />M <br /> <br />3O.b WAS CON8liNT 0IW'fTiD'I <br />DYES iUNO <br /> <br />t ""'.PrflIJ <br /> <br />M.A. Tanpkins, M.D. I Gran:'i Island Veterans Hane, 'Gr,up Ialard, NE 68803 <br />... AIGI8PIM OIl FU08Y REGI$TIWl /MI.. ~ Yr./ <br /> <br />FOR VITAL STATISTICS USE ONLY <br /> <br />Place............._......A ................................8 ................................C................................o ..............._.......;.......E ......................._.......Parlll......................TMV ........................... <br /> <br />NSC .........-........................-.............................:...............,.......-...................................................................................................................................................... Census Tract No. <br /> <br />Work .........................................:.........................................................................................................:.............................................~....._.............................................................................. <br /> <br />UC..............................................................._....................._.........._............._.....................................................................................,.................................................. <br /> <br />Reject ............_............................................................................................................................................................,..................,.................................................... <br /> <br />A. PrIll..... ..." ... 1l1li "*.....,. 1f\IIIIIIIlIIII4!l. <br /> <br /> <br />I hereby certify this to be a hUG Jlld correct copy of the original filed with the <br />State of Nebraska . ..~. ~.' I <br />..., by ____ _,~~. -dV ~d.-J <br />..~..~.::taY ~ 199/' . <br />-7 ~ ...Notary PubliC <br /> <br />.J;.. IiElUnAl MDT. AllY -. Stats ~. I H~hraska <br />1m TERRY L. LOSCHE~Sl <br />C E ..l,"-:J, <br />, ~';:" My.. omm. xp. _, <br />