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<br />DECEDENT NAME <br /> <br />STATE Of NEBRASKA-DEPARTMENT OF HEALTH <br />BUREAU Of VITAL STATISTICS <br />CERTIFICATE OF DEATH '1- <br />MIDDtE .....ST SEX <br /> <br />83...J)OlH4::; <br /> <br /> <br />I <br /> <br />I <br />I <br /> <br />atient I <br />INSIDE CITY LIMITS I <br />~~:~y ~.S or No) <br />---rAS'f- <br /> <br />~ <br />1~ <br />li.%.l' <br />t~.o <br />':1 <br />~i <br /> <br />~~ ~ 2.0. <br />-liS,;., PRONOUNCED DEAD <br />~~it 'i (Mo.. Do)', 'fr.) <br />v:;z 2<k 2Ad. <br />...:: a 6 On the boai. of .".....;....Ii_ ....d/o, in_llovotion. i.. '"'l' o,i..i.." d...th o<<v.,.d at <br />~ 8 ~ the ti..... d..~ ....d ph..,. and d... to .a. ~....oe{Q ."'t.d. <br />,2...{S,llnat.........I r,tl.," <br /> <br />2.4b. <br />PRONOUNCED DEAD (Hour) <br /> <br />M <br /> <br />'" <br />DUE TO, 01 AS A CONSEQUENCE Of, <br /> <br />Inl....alb._...on..t....dd...1tI <br /> <br /> <br />WAS CASE affEltED TO MEDICAl <br />Ex.A.lrlUNfl 01 COlONEl J \ <br />(Sp"''', hi .... No} f\..JO <br />2.. <br /> <br />STIltEy 01 ..f.D. Na. <br /> <br />CIN O.TOWN STAn <br /> <br />300. <br /> <br />301. <br /> <br />WHE~~"i::ij;;r,SSqoPY CARRIES THE RAISED SEAL OF THE NEBRASKA <br />ST~'t.E':I).EP'All:l'1~t~NT OF HEALTH, IT CERTIFIES THE ABOVE TO BE <br />K,~R..ltE COPY. '6)sAN ORIGINAL RECORD ON FILE WITH THE STATE <br />DEPAR;MEN~ g~'~~ALTH, BUREAU OF VITAL STATISTICS, WHICH <br />18;:fH'E LEGAL' :D;tj.>OSITORY FOR VITAL RECORDS. <br />';X-,' \>:~~} <br /> <br />D' " C'~'ipp,~ ,..... <br />LINCqL~:~~'SKA 7, <br /> <br /> <br />~ <br /> <br />L <br /> <br />~ <br /> <br />L <br />