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<br />I
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<br />
<br />STATE Of NEBRASKA-OEPARTMENT Of HEALTH
<br />BUREAU Of VITAL ST...TISTlCS
<br />CERTIFICATE OF DEATH
<br />
<br />79
<br />
<br />03160
<br />
<br />DECEDENT
<br />
<br />I
<br />
<br />Fo.\eman I E.thi.l
<br />jlNfORMANT NAME RELATIONSHIP MAILING ADDRESS (STUET ot u.D'1-- CItY OllOWN. STAll. ZI')
<br />
<br />r I'/ok. Cluvtw Svoooda.-Hu.6band-S 10 E.l1th-GJiW1 .!lland
<br />CEMETERY all: CliliMATORY-NAME lOCATION CllYOI:TOWH STATE
<br />
<br />21,
<br />
<br />t:' .~~7Ng.; \ otl "
<br />~ .... \ \ _' (> ""I.
<br />l~ .fs.;.__<Htdral.j~ ..~-- 'r-J y _~....o.L-~'
<br />.to I DAn SIGHED (Mo., DOT. Yr.) HOUR Of DEATH
<br />
<br />j~ ~3b. 3-.:l '-..1 - I i \r:k I/-:)J;':> ..41 u~
<br />~l ! OAT! Of DEATH (Mo.. 00)'. Yr.) i;;-~_.' '-'~~~;r~~ DEAD
<br />
<br />~. l23d. .3 - / 3' -- "7 '1 __l_ t~-A.
<br />~ ........ AND AD""'" Of C""'I" (PHYSICIAN, COION'I'S PHYSlCI'" ", COUNTY ." ,Y1 ",p." P,i.')
<br />
<br />~GIS__ Ivan &teed M.D. Uni.u9JrAit'y aft !JF IJl1diMJ f'11"~"lt..c~n&.I.i.,~eq',1
<br />
<br />''''''9__1. '1:J:-/r2A,"~ 1,6bU4l<,,:t .x 1'7
<br />27. IMMfDtATf (ENlE' ONlY ONE CAuSE PER L1Nf FOI (oJ. (bi, AND (e)J 110-.-1 b__......~...
<br />'AfT
<br />~..) L -'r- ~:{' t A"...-.-.:; f-
<br />DUf TO. oa AS ... CONSEQUENCE Of~
<br />
<br />A.
<br />
<br />'-k,
<br />PlONOUNCED DEAD(Hour}
<br />I,..
<br />
<br />M
<br />
<br />M
<br />
<br />tb) l' (\ r- J ' c. '- (I... r-,... L,,"'Y
<br />DUE TO. oa AS A CON$EQUfNCf Of:
<br />
<br />~ :_"1 ,.~....... " (\
<br />
<br />(11 .;... ~.(.e S
<br />! lnterwu'.,..........alllf.....
<br />
<br />l I hOl1r-
<br />: In___ b....- __...........
<br />
<br />, 200,
<br />I :=~~~)
<br />~
<br />
<br />ACetOl"", SUK.1Of. HOMKIOl. 0"4011, ,00ft Of iHJUt, {Mo., 00,. ~. j
<br />at nt4DlNG ''''VUltGAllOft. (S__.,,; I
<br />I
<br />i JOb 30e.
<br />I:::: ~I~~-:': ~::::;; I..... on_t. locl~.
<br />I
<br />1301,
<br />
<br />
<br />! AU10f'$Y
<br />.1(SPfij"'1~~~NOJ
<br />28. -1/ l
<br />Of$ClnSl! HOW tHJtllY OCCUtllfO
<br />
<br />I Yf!! ~~ r- $
<br />I WA.i CASt: .EHI:ItO TO MIOtCAt.
<br />! UAMaHU ,01 ComNII
<br />(s,..cu,Y'..wNoJ
<br />29. A./,~-
<br />
<br />Ic) l~ or'o...",. "I C"- r- In, ..- ':-P-C.; C
<br />PAIl 01"1' 3lG""'tCANl CONOIllONS C:0004ao- c_...b..ltooQ ... d_llo ....1 nol .,.lo-.d ! '''It Ill. If ffMJt,lf, WAS T"11f A-
<br />Il \ PtlGNANCYIN. THI. ?A.$T:I MONIHs.t
<br />
<br />3ad,
<br />
<br />5THIT 01 "'.0. Na.
<br />
<br />cny OIlOWN
<br />
<br />SIAU
<br />
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<br />RECORDERSMC:~'~9:,'!-' 1, ~,(G/;;. 1/i~;,
<br />_', (( ,/ /'.,//1/,,, {jL,( ~A/
<br />/
<br />
<br />'t _J, -,-
<br />Rell. of Deeds
<br />
<br />WHEN ,Tl}IS COpy C,1\I\RIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPAR~~NT OF' HE~TH, IT CERTIFIES THE ABOVE TO BE A TRUE COPY
<br />OF ~~RIGIN~ ~QRD ON FILE WITH THE STATE DEPARTMENT OF HEALTH,
<br />BU~.I.j- OF VITAL S'l'}\TISTICS, WHICH IS THE LEGAL DEPOSITORY FOR
<br />VIT~~CORDS. '
<br />
<br />~'4~
<br />
<br />DIRECTOR, BUREAU OF VITAL STATISTICS
<br />
<br />.'
<br />
<br />~
<br />
<br />Issued Oct.
<br />
<br />19, 1984
<br />
<br />LINCOLN, NEBRASKA
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