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<br />STATE OF NEBRASKA-DEPARTMENT OF HEALTH 84 00"5393
<br />BUREAU OF VITAL STATISTICS - ..t
<br />CERTIFICATE OF DEATH C-C, (/) .
<br />- o,e,,"W-NAME fiRST "'OOt{ ---iAsr-.-1SU lOAf! Of OEATM(Mo., 0." Yd
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<br />lntho,.. .f>cJ(Sp..dfY} GenMft. ek)(SPK11t) :f (Y.-s.) I MOS. : DAYS I HOOltS: _ M:lN$,
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<br />ctt"f AND'SfAff Of '!1I1H (Ii /'tot;1t U.$ A_. !CI1IZEN Of WHAT cou-~ r~":I~I? ~~t~~~Ep. ,'_ t NAME Of 5POUS!:(tf'.....fo; gt..'.JIu,j~.Jl'",o,m,-j
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<br />.. dg~n,r;ebr 1. v coP, ho ',arl"1.ed .11. Olaudie Pritent\rd
<br />SO(I"i SfCutttv NUM!R jlJWAt occtJPAnON ((;;.,.. lind ;:If_A: d~M-dl,<;i;;g--;;;trl(INn Qi'UstN~1W COUNTY Of DEAlH
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<br />12 507-10-':505 I,,,,, vonstruction !!:ng:lneer i3l.:Retired ".. Hall
<br />CliY, TOWN Oi: lOCAtlQH Of. OlAf" ~l)E CITY llMllS I HOS9lT AJ; Ot OTHU.INSTITUTtoN - HQlM" (If nof 1'1\ .ithttt. If. HOSl':_'oa-JNS'f.l~..,OQA-':
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<br />IfSlDENCf. _ SlAtE ! COUNTY ICIlY. lOWN Olt tOCAl'IOH ----r5T1l:EEt AND NUrAen
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<br />-- -fA'fHEA: _ NAME fl$!.ST ;.\IDOlf: LAST 1 MOTHER - MAI0tN: flut MIDOlf
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<br />I.. Ti.o,"05. I,:. Cerreher ~ Edna Ford
<br />... WAS D(-CU-SfO fVfR tN tj S ARMfO fCIKU'1' : lNfOR/lotAWT .~ NAME _ RftArfONS/'lf"~ MAttiNG -"-DO-lESS /Snf-fl oau'.o. NO.. Ctn--o. TOW"'. -StAU. -llPJ'
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<br />EM.....lMf.-5fGNATURE" HerNSi' NO . FUNEtt""-l HOME- NAME AND ...o-DU5S
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<br />~" 1tl<;lj#.:-'I!A!!' SD81dinf,;~ebr. 68665
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<br />WHEN THIS COpy -CARnES THE RAISED SEAL OF THE NEBRASKA
<br />STATE ~~P~RTMENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br />A TRUR"COPY OF AN QRiIGINAL RECORD ON FILE WITH THE STATE
<br />DEPARTME,N]:'. OF HU:L'1'H, BUREAU OF VITAL STATISTICS, WHICH
<br />IS THE 1-E{~L;,-DE:PO'S'-ITORY FOR VITAL RECORDS.
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<br />DIRECTOR OF VITAL STATISTICS A1~ ASSISTA17 STATE REGISTRAR
<br />LINCOLN. NEBRASKA ISSlied AprffZO , n1981
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