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<br />STATE OF NEBRASI(A-BEPARTMENT OF HEALTH 7 ~ ~ L ~ ~ 7
<br />BUREAU DF VITAL STATISTICS
<br />~3«-- ~ (}Q~' ~ i~ CERTIFICATE OF DEATH P3 _ Lrg ~;
<br />1
<br />DECEDENT:-NAME FI 5T MI E lA3T E% OATF OF DEATH (Ma., Doy, Yr.l
<br />~~i.e Soplt.ux G~.GLcuju~ x Tema.Le Ilan 30, 7979
<br />RACE-{e.g.. vJRRe,¢~la~ITi. Anrri<an•g1G}NJDESCENT(R.g„boFion, MU.i<vn, AGE-bn E~nM.y~ UNOERI YE4R~ UMDEAIDAY DAif OF CIITH (Mo., DOy, Yr.)
<br />tadien, ep,j ESPeYSfyj VlF ~ r•r 2 ~C»rnFan. eN.) (SPecilFlf.~~~~ (Yn.l L, ~ ' MOS: ~ 6ATS' HOURS . MINS.
<br />tW ~, c ,~ 7, 7893
<br />- 4. 3. 1 da. 6b. M. 7.
<br />n AND- Tx E6F EIATH (71.roE :n U.S.A., CITIiEN OF WHAT COUNTY MARRIED, NEVER MAR0.1E0. NAME Of SPOUSE(I/ri/e. giw roiden nomej
<br />ea~e.<ean,~.j'r3ae.{sta; teal%fittsktt g (l. S.:•i. ~oloaw~EDf rvo~rsP.rihl'tt I32Zt f!. G
<br />SOCIA4SECURI7Y NUMBER USUASOCCUPATION{C'.w. ki..d a/..oh done dunng moFf EINOOF BUSINESS ORtNDUSTIIY (iCOUNtt OF DEATH
<br />,508-46-~7$7 Iofrerkingli/e.e.enilroFi.ed) ~~~~,e,;,, tlarnea.t.Le I t{a_t.C
<br />-. ix )ID. ISb. 14a. -'~
<br />- C1tt, TOWN Ot EOCATION OT DEATH INSNE CtTY UMRS HOSPITAL OA OTNER INSTTFUTION -Name (/! net in NFber, IF NOSP, OR 1N51'. lndleere DOA,
<br />~r2und 1'a£nn.d 1rsP`idy~e,Nel ~¢.d.r[-:~',1'~"ei%jerrr 1lun~.i.ng. 1{one ~a,roeFr.'r-lTLp~itiPaP«+h)
<br />E4b; X14<. f
<br />RESIDENCE--STATE COUHtt ICfST, TOWN OR tOCATtON STREET ANO NUM6ER INSIDE CITY IUiITS
<br />{{~;,r~2r~r3kc ; !ia-1.C Crjert0 i ,~~: 7 ~TSP«'hrar~~.Ne)
<br />13v,- 13b. tic. ~i3d. SSe,
<br />A H R-- f iRST MfODE U T ! MOTNE -MAIDEN NAME FIRST MIDDLE
<br />, ' !{pa)/y,~„ ~71R~'~,. j.:)ILS.iE~470~. j 17. F.l..t.~it.~12.Cf1 ~tl1LF.~ Xa P~L(.PJL
<br />WAS DECEASED EVER IN U.S. ARMED FOtCESi i tNFO¢MANT-NAME-ffEAT1ONSHlP- MAfE1NG ADDRESS ISTREFT O! R.F.D. NO_ C1TY OR TOWN. STATE. Zth
<br />r.E1~ ftF m. a«..e. wed tler« vI mm<.> -
<br />~,E, rw It¢.~ea2ge led.Lrzny.-ooa- ~?~' 1 t3ax 7$, Cn.i,LO, Re 65821s
<br />_r BURIAL Genro*ian, R<rnoml 6AT CEMETERY Ot CREAUTORY-NAME jTOUTtON CITY OR TOWN STATE'
<br />xDa. ~utr:¢C j2¢bP~131%9 ~xa. tr~.t. P.L.e:<~c,.n.L 'xoa. Ca-i.zn, Ile.Gha~kcL
<br />EMRAUAER-SIGNA7URF i 1CENSf NO.~, t FUNf RAI HOME ~-N4MF AND ADDRESS I5T[FET OR R.f D. NO., CITY OR TOWN. ETATE, ZIlF
<br />-._xl. ~{ ~ (/~ ~zR~ i2:- ~tp j.e.L iur:e~ce,t:. nor,_e, t::ood ::•i.veJi., r{etj'~k.¢ 08883
<br />- j r<~ r w k ' ~ « aep d a ~ d.. <. , . o.. x.. ce«<., .w..a.+n, e.,dt.. I.-« r...:. ~ dwdr «..,..w aF
<br />~r 1 ~+ ry and Olv<e end dve p N. •vuptd rbNN.
<br />x3a.firt+en+'rr+iW7~-~'CG~`~`G-_f )')•,!~ y p.0 Ixb.(S~gnw.r. awd i;M.1-
<br />i>• : DAT~~i Nf (MO, De~7, Yr.l-- HOUR OF DEATH -j_. __C •i A I N (MO. ay, r,
<br />..z3-I r .+-
<br />u~f IxXM• ~-.~~ ~ / 1 ~23c. "t f'~ ,'U~( M ~I+k`Z a~xab. iTlc M
<br />n; DATE OF D€ATN (MO_Da Yr.) ate :PRONOUNCED DEAD PRONf_.UNCEO DEAO(Mour)
<br />Z yi-.. ~, ~ !7i :-off; ilMO.. Dor. Yrl I
<br />~x3d. i wit- r ~-ft i u -xaa ~xae M
<br />NAME ANO AO f53 OF CEAiiNER (PHYSICIAN; CDRONEYS PHYStC1AN OR COUNTY ATTORNEY? /iype o. PnnU
<br />3.
<br />RFG4STRAR ~ ,.:/F/+~j[/ ~ ,.--'} % ~ DAi CE1VE0 dY/REJO)STRAA (Ato., y, Y/r/l9 y
<br />L2w.lss..w,.i! ~f,' `°_ ;,':"{-'~_` _.2,~~~r= ~"~--C'„C- ,~,f1A.~7j/LZ"'E`~f ~/ / •~`/
<br />i~" IMMFIN_ A E CAVSE NFft ONl ON CAUSE PfA kNtf FOR ta±. 6--"~ ~
<br />#~ Y._~ / (b/. AND (e F1 b~~~IIwwl 6eppn+aFl.7-dnd" M
<br />DUF 7D. O! A CON3EQDENCf OF~ ~ ~ { Inpr.el b«wen wr.r end dw.k
<br />R1
<br />DUE TO, OR AS A CONSEQUENCE OF; fn«.w1 b«wen e«« end dwd
<br />id
<br />#AET ¢ k, Kk[t C TfONS.,GM er.nb«in, p de«+M.. a«+.feM X laei W. .F FEM+kE, wAk irlFR[ A U10#kY WAS USE KF£Rtl6 ro N[DICAE
<br />II // t I fRl.^.NANCT IN 1NE #+ET) MON`NSt Sv.<.Fr r« ) ' ELwtpkR Ot Co~~~
<br />It.. - - / ~ Ne vsP«.h Y« « NyF . .
<br />_ -~ - 'FCl-t1. Ysr .' No xe.!'t'r. 24. 1''=
<br />ACCADENI, SDKFDE. NOWCIDE, VNDtT t~ Wi[ Oi INIdEf LArs., Fvy, r, I iNOUR d INtUli ~ (!fKEIR NOW' UUYRi OCCVRIIED
<br />OR #ENDFNO tNgSDOA00n tSwd,t
<br />SDK. ~ 7D6. ? 30c. _ M ~ lDd
<br />T~n1FUtT +T WOr< ! #tAGE OF Mrl4tT- H ner, Iarm, .veN, lonwr. ~. lCK+1rON StzEEt OII e F O Ne CITY OR TOWN SiAi!
<br />~ fFapuy Y««NH ~a+fw JNn)dr;. e4-F$Mrd#) -
<br />~ 3D.. i xir. _ ~ ~!
<br />t • ,a~
<br />~;'~••~ ;CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />'ST'~`$'°D,fi•Pat~t~IlT OF HEALTH, IT CERTIFIES THE ABOVE TO Bfi
<br />~r~~E C+aP'Y' Q~i AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />HBIAItTT1ENT~.4F4 ~i8ALT8, BUREAU OF VITAL STATISTICS, WHICg
<br />• ,~~~ E' LEC'~L ,D~FQSITORY FQR VITAL RECORDS.
<br />~-tire" _ ..__.,5 P
<br />H Tn °STATISTIGS AND ASSISTANT STATE REGISTRAR
<br />L ; issue.: January 14, i983
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