|
<br />'f oa- NlHT fH
<br />f~fNJ:
<br />f lN$ltuCTlON
<br />"",""AI
<br />
<br />S;iiTi Of iiEIUiKA-iW'A/lTIiENT OF HUlTH
<br />BUIlUU Of VITAl STATISTICS
<br />CERTIFICATE OF OEATH
<br />
<br />54 - 006210
<br />
<br />!,.BerniceA11en,wife, 1410 N Custer GrandlslandNE6~8f
<br />~ UMlTfaY at CIfM"Uoav _ N..v.lf~-- -- l.OCATJON CtTV'Q'HOW'N stArt
<br />
<br />!,ij.t. McPherson National Cern. 2OdMaxwell, Nebraska
<br />I fUNfRAl'MOM,f -NAME JiND ....Oo.tESS (5lun O. "'_0, NO, C'lY 0I-1OWJ( "",t,".',1'" ~:
<br />
<br />~"'}.t'( I Adams & Swanson, Box 489, No. Platte, NE69103
<br />! ...j:; I DATE SfGNfDtM(). 001. \'r.} ,..O.U....OfO!:Al...
<br />
<br />li~a ~ 2"". IA-
<br />,MOU' Of DfATH l;f~,;.1 PltONOUNCE-D DEAD 11'-PRONOuNcfo'-DeAo(Ho~'
<br />
<br />1'184 i,l< lO:39__"_i~)?ril:,D.~'" . 2<<1.... .. ....
<br />
<br />xr- I ~ ~ '-~- I _..t:~:-~ !;::::.1>.-..;........~pi=":...'~j~......"-:,>'~. Opi'"-~__~..d^o:w~~--_
<br />-..... "......llll..-,-.,. ~"~--..; :~~,..;>;,."", -~ I ...
<br />: 23d.I,$;.-n-" :<ff4-J . T. ft.1 ~': v ~ 2~..(,Sj_..._...tu..-a,..j ,jtl.)'"
<br />
<br />.. , , ~ :~-~:: :7:' ;a ~~m:~':H'~~'~~':: M;~'i P;:7lA;e: ;:~~~~~':(~rP~;:~"~we 11 ,G rand I s I and, NE &8801
<br />
<br />. ! I ~$1'" I OAlf REcelVeo IY RfGIST..... (Mo , Do)l'. rJ" J
<br />
<br />~ 260.(1i!l....vw.J... i 26b
<br />21, lMMtOJAlt CAUSE (EHrEt ONtY ONE C"'USE PUt/NE to_ (oj, (0), AND fdJ I.._~i b.l____-.alll.-d.o:dt
<br />1 ....
<br />i i., Bacteremia
<br />1 OOl lO. 01 AS .. CONSEQUfNC! Of,
<br />
<br />! 'M Infected arterio-venous shunt
<br />Out TO, ~ .$ . CONSfQUlirKf Of
<br />
<br />
<br />r Df(fOfNT-NAlr4f --~-f~--"-'-'-'-"-~Y---'~--""Li1r--r(j-'----~--P)Aff ~~-_..._-~_.-
<br />I 1 Melvin __Roy Ai ien " Male 13 July 14, 1984
<br />lAC. c...., Whi~, 11'IJC\. A_ft;otl OIfGtN/OfSCEN'(..-g..lraHo..,,,",,-Jlkotl, ! ....GE -l.cNt .1"'''''''0,. UHOU. 1 n.... I uNOft l'OAl .rATf O'.IU:TttfMa" Day. Yt,)
<br />'"",, t'eH-SPMiIy} ~",,,Jc.HSpecf/,} ('(rIJ L4 MOS. . DAYS I HOUIS: MlN$.
<br /><. _. UnknOWn . 0 .: 6<.: 7. March 15, 1920
<br />~NO-STA"OfaJITtf( tJOthJU.s.._, jC.fllHo;.WWATCOUNlty wIOO:io#~~~:~ify) lNAM!OfS~ f'I".U.._9~__.cf""""O"'.J
<br />~g"dh, Nebraska . U.S.A. 10. Marrle~ l"Bernlce J. W'nters Aller
<br />SOCfAlHCUftn NU..n U.w.l OC(UP"T<<)N.(GM-lind 01........ Il1o_ Jill';",""" KtNOOfIU$lNfS,SOIINDUS11Y _,- COUNtYOf:' OEAtH
<br />t;06~01-o809 ol_"i"fl "..'...., "Nti,<JI1 .' Glove ma'nufacturi1ng. H 11
<br />it . . ':Io.:>a es Kepresentatl ve 13b. company '140 a
<br />(IT'i', TOWH0I1OCA.noN Of OUfH INSIDe CITY UMtfS HOS,..TAl 01 OUff.tNSTfTutfON -'Ho_ III .,or-,IO .ith..., tf -HOW: OI_fNST lotdiiet. _C>OA:.
<br />... _ __ ... . __ 'J _~.. J. ,t$D...u...cV.......U.1 l...;-__...-.t~) - o........,Jf~ .....,; ~'ofi...ltSp~i&'
<br />,%,,"00 ''''dno j,.-,TeS- - -'I~.;;;:-VA-MeCfrcal Center I,... Inpatient
<br />IfSlDf..-.cE~STATf jCOUNTY lefTY. rOWN01 lOCAn.ON IST.I:UT_.-ND'NUMa'. IIH5tDf'-CJt":_DMii
<br />
<br />,...Netlraska "b. Hall f"kGrand Island ,><11410 N. Custer:~Y:;"'_N'
<br />,A I 5T M.umu: u. TH t..... MAIDfN NAME f IS IIliID _L.l!f'7';~
<br />
<br />K.. ..u..............
<br />
<br />F;~~~:: :~::.:'~~:~~.::
<br />
<br />i .
<br />A 11 en! 17 (dec. ) Sarah
<br />: INfOtMANT _ ""JiME - 'ELA. rIQNSH" - MAfllNG AOD.ESS
<br />
<br />Mae HW;Jhes
<br />!nutf 01.,'_0_-"",, on ()flOWfl:l;- Sf,An;l
<br />
<br />4 Days
<br />
<br />lnt.not t........-_t,....d-~
<br />
<br />
<br />~ n....".._
<br />; ltl_":~=:"""~$-:
<br />
<br />Ii
<br />
<br />: 18 Months
<br />I WAS UU,U-'f'HfO~tO.....OIC4t.
<br />i UAMlND: 01 '(:0I0NfI: ,-.
<br />II;;"'" r.. '" Hot No
<br />
<br />us Tract No.
<br />
<br />End stage renal disease
<br />,..t SiGNlffCANt CONDfTlONS~C""'_ l_,........i>>e to d_" ...., ...,1 ..I.~ j ,,,.-1' Itl II' '~-l, WAS ftitlll " ! AUlO"'"
<br />II .. . 1 '.fGHANCYI"THf-PM"1l'OHfH~' )(S,..e;fyy.._",..l
<br />Hypertenslve cardl0vasculaT dlsease' y" C No ;:~, in No
<br />~c~=-f~i$=~" ! o-.tt Of ltotoJU*l' '.......0<01"_ t.' . :~<:ifI~Viiy i OIE$Cldf HOW I;uun oc<-u.uo
<br />
<br />t,- '_'_~:-." __ _~_._, .'_ ; JOb l J(k- lit J 30d
<br />'''''_. _ _ "'1-'lACJ ~ If'fj.UU _ .II, ,"-, '';;'';':~~I;''-:;;;:;:---~--- ".~--fiQ{AfioN--'----'-'-'''--S.''-fftO. U.O. No
<br />I (s_-Jr.f'.....~ !qJ~b...W"'O....IS~'J
<br />
<br />... ,.... 1>01. _______._~__,______.__~~___
<br />
<br />(:IN OIl!OWN SfAlt
<br />
<br />'~'~~'T2~
<br />
<br />
<br />?"
<br />"(:! ./
<br />I."".. /'_. ./
<br />C." <;.._".....w-.
<br />
<br />STATE OF NEBRASKA
<br />COUNTY OF LINCOLN
<br />
<br />I HEREBY CERTIFY THAT THE ABOVE IS A PHOTO-COPY OF THE ORIGINAL CERTIFICATE OF DEATH
<br />FILED WITH T~E BUREAU OF VITAL STATISTICS IN LINCOLN, NEBR~S~~.
<br />
<br />SUBSCRIBED AND SWORN TO BEFORE ME THIS
<br />I A --,.-..-1
<br />l~ ii.MMflWMl&CH I
<br />~ __ ...._...11.1111
<br />
<br />(~~
<br />
<br />DAY OF ;, icd:) \...... ') 1984.
<br />
<br />/~3? N&i~~-j
<br />
<br />I I
<br />u
<br />
<br />I
<br />L...
<br />
<br />L
<br />
<br />~
<br />
<br />I
<br />L...
<br />
|