|
STATE Of N[~Ai11A-OgARTMENT Oi NEAtTN
<br />tYAEAY M VITA/ tTATI{TN:t
<br />CERTIFICATE OF DEATH a . ~. _ n ~~ °-- () O ~ 115
<br />N -NAM! t M 011 ! N (w.. •r, I<.)
<br />u a e ke le
<br />uce-N.D.. WAi1•. • E. AArk•• aralN/oescew7a.~.,Npl»,,Af«K... Ace-N.u,r..w uN E 3 rEU u 3 wr wtlptlEr«rAf...D.r,f..)
<br />Iw...r.J/sl.rit71 tNr.....N.1rf...Yr1 rrrr.) MOf. DArf NouEf, rNq.
<br />.. White American ~D w. 80 w. ~ k. ~ 7. A ril 1 03
<br />CI • fM1lglN1N (M A«i. Y.f#., CIi12fNq WNAE OYNTW MAEM D. NEVEl MAlMlD, NAAIl MS/OYSE( .iti; Di••y:/,•yyl
<br />Mw f•••D/I WIDOWlO. DI11OfCE0lSp«i1Y/
<br />~~
<br />f. Peru I111nois
<br />• U lo. Marrie n. Leth Mae of
<br />SOCY/f[CUNl1fNWlflE YfYAI OCCY-ATNfN(Gi.•Yi•I•I •«E Mn•/wiry AMN RIND OF fYNNlfSd NlWftEY COYMff!O/DEATN
<br />NwWiy (iN. •ww ilnFn/) '
<br />u. 8-38-1 lf.. it Fa a In. I .-
<br />cm,TOwwdttxAnaNdoutN INNOrtmflwTS NDSNU3dofwEEN+snTUTIDN-w..(N,..I:..iw.: DNOrsarsvw:.,.Daw~
<br />!fp«Yr r««M•1 Ei.•rN••r••I •w.wr1 OrlyN«y[rr. V'. Ny.wrlSAw/If
<br />I•\. Grand Island Ne 14. Yes I .3040 Stolle Park Road Iw.
<br />![AD[NC!-STAfI COYNtr CITE. t0WNdl0CA7I0N ST[EEf AND NUMfEf tNS1Dl fJrrlWllf
<br /> lfp.silrr««N.7
<br />w. Is-. I>c I>e. fw.
<br />A -N t MI ! MOM -MA N W
<br />I. Philli _ _
<br />^
<br />-
<br />WAS DEC DlrFE IN U.f. A
<br />EMIO FOEC[Si INf0EMAN3-NIMF-EElIF1ONSNlp-M110.1NGAq~[y
<br />flOp[.E.D.NO..CM.OEYOWKENILEYI-
<br />~TK».-•Mt
<br />l"+•.•+--••»••^».N-^N•i 3114 Sto~ley Park-Road-
<br />~
<br />u. No w.
<br />fUMAI. C.•M•1i••. 4•,s.•1 DAi CWEIEA OE CEFMAfOEr-NAME S0CAT1OM Clir dTOWN' SiAi!"
<br />7w. Burial ]a. Feb-17-1984 aa.Grand Island Ceme r 7a:G -s N
<br />EINAIM! WNA TUlF E Y S O. ~ /~j •7 fUNEEAt NOME-NAME AND ADOIfSS 131[!0 E:r.. Cin O[ fOwN, ftAt[, IYI
<br />2
<br />/
<br />l 112 W.
<br />i2d St.
<br />:1. n. A fel-Butler-Geddes 801
<br /> A /Ar o•r, DATE IGHED (M•. D•r. r<.1 N YE.OF. DEATH
<br />'~ 7f.. / ~ ;t h
<br />°40 :.•. 2 17 84 7E-10:52 A. „
<br />7
<br />~ OAT[ N (w.. Ds,, Y.J MOUE OF DEATH iii _ /EONOUNCED D[AO /WNOUNCED DFADlwwl
<br />~
<br />~ Vet. (W..0•r. Y..l
<br />
<br />j~ I• +. Ewr W ., s•.wwgw ...A «<..M •r r. w.•. d.N •W ,im •w,1 .„• r N,r
<br />.•wrlrl rr,r,E. Qa~ D. W .M/w i.+ENEw, i. M•M wwM V
<br />rS• ".r. /•N •w/ Nw• N M• w 4,rrrw/.
<br />
<br />NAM! ANO AOOEESS O! CElilfiF! TINY ICON, COEONE!' IMYSKIAN d COUNtr ATTOWEiI lirp• e. Iri«)
<br />:s Steven J. ;Moeller, Deputy Hall County Attorne
<br />EIGISTIAE
<br />1~
<br />'
<br />'~'
<br />~ OA7E ffCEIVFD Ef) EfGISTUOLL
<br />(~M•., Daf. Y..)
<br />A
<br />/
<br />4
<br />.i C:!!
<br />l~-{L.
<br />7w.I3Y•w•'•l~ / ~(iiY I.Gi, -~/a~Ai't/ -
<br />~ y
<br />~- CY~-G/ /
<br />7
<br />1
<br />77. UAMEpATE CAYSE (FNIF[ GNSI ONE CAUff ff1 ll F lO1
<br />), (6), AND (</1 NN.wI •rw•« «rA •.• /rwS
<br />r
<br />-AEi
<br />.. Sepsis
<br />DYE 70, d A CONSFOUfNCE OF: ± sr,..l ~•,,,,•,, .,,,, •y •„~
<br />IN
<br />DYE fO, d AS A CONSEOUEMCF OR bwwl N•N,•r «M •M /•r~
<br />NI
<br />-YI D [ fIGMY1CANt CON01f10N!-C«A'w«r <»•:M:y ti •,M En1.W <r4W rA[ III Ir rFAMIf. WAS IN![! w AUtgS7 WAS CAN EErlMEO TO EIFDICM
<br />D rNG1MNClw TN[rA311MOlfrW7 (Sprit, YwrNN [SIMDIN OI CO[ON![
<br />TN O N• ^ lfpr:l, I« w Nwl
<br />7f. n0 79. ves
<br />KCSDlNr. flllClp. NOwCNN, YMp1., DAII d 1WYw IW.. Dy. f..l NW[ 01 1W Y« DESCEU[ rqw w3WT OCCY[ND
<br />p MrrNrrO MWf1iAT10N. (ipwilel
<br />7w. ]01. 70f. M ]Od.
<br />•u1MY a roEa MACE ar wlWf- M r.1«......r. I.rMr,, 1oc•rNMr srau p [.. o. w cm d 10tH safe
<br />rsA.+r rrw NN .N+. ,."/i», .N. ISp.:1.1
<br />
<br />j lFa27~T$ DOPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />„STATE~DEP.A~TMENT OF HEALTH, IT CERTIFIES THE A80VE TO BE
<br />!~ TRUE GtfP]f:~OF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />DEPARTMENT QF>`~HEALTH, BUREAU OF VITAL STATISTICS, WHICH
<br />iS, GAI DEPOSITORY FOR VITAL RECORDS.
<br />~~~~ __.
<br />R H., BECK Issued February 28, 1984
<br />ASSISTANT DIRECTOR OF HEALTH LINCOLN, NEBRASKA
<br />
<br />
<br />
<br />
<br />
|