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<br />STATE OF NEBRASKA
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<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTM~'1i>(jfII;.&TH AND
<br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE-op.l~l,r;(!<. ON
<br />FILE WITH THE NEBRASKA DEPARTMENT OF HEAL TH AND HUMAN sERjJI~e!S'; VITAL. Of>.f .
<br />OFFICE, WHICH 15 THE LEGAL DEPOSITORY FOR VITAL RECORDS. .: ::c::,. ....-\~ T E <i~..&_'~ .......
<br />
<br />DATE OF ISSUANCE 4 <- AJ. ~
<br />200 8 0 96 2 ;; & ~~~ 1J7 o~'t1:~~~~~
<br />
<br />1", c;-pEPARTMENJ','25!!~A1..:Pjf ItND
<br />LINCOLN, NEBRASKA · t ''Jrly,~~ sEAV1.~..... ~;, _:~J
<br />t 1." (- l;; '1 t, c" ~ . . )t ."
<br />STAtE OF NEllASkA- DEPARnmrTOF HEAL11f AND HlIMAN SERVICES FIN~~ SOM)itt.'.. . r~'~ '\ ....
<br />
<br />CERn:-~ ~~EA'l1f " t \ ,i U L V 'I. " ---
<br />(,ASl 2 SU ~, DATE OF
<br />
<br />Female December 23 2003
<br />UNDEIl' VEAA ut4llEA , DAV e. DA E OF 8IIlT" 11lfl:"". 0... Y_I
<br />!;ill UOS I VS 5c HOUJIS lIiNS
<br />
<br />OCT 2 4 2008
<br />
<br />1 Dl:ClDENT._
<br />
<br />FIIlST
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<br />....DOlE
<br />
<br />
<br />Karen
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<br />Ka
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<br />Se tember 18
<br />
<br />1 41
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<br />.. CI'!'V,UIIID STAlE Of: f;WR,.... .~r!t;1I.,uS.~ "..,.~I
<br />
<br />J~r:an~ ,J;sland,Nebraska
<br />~ 7 SCX:~L SI~Tt" ~1lI
<br />
<br />~~08-42-3684
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<br />e.. PL~( oF [EA",'...
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<br />I DEA~
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<br />~ DDOA
<br />i 5il '''slDE CITY LlUlTS l ~ COUNTY OF llEATH
<br />
<br />i Yo. [j tOG 0 I Hall
<br />Ie CoT' TC_OOI,OCUOOOo tel STREeTANON\M8fFI 1/fJC/utIfI{IZ1/J~1
<br />
<br />1615 N Ta lor Stre~'803
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<br />OT..EA
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<br />D~urtl"'i1~
<br />o """'e
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<br />o ON<,*"',,..
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<br />~St. Francis Medical Center
<br />It c,,, TOWN-Oil ~OC'TOON OF Of,AT"
<br />
<br />~and Island, Nebraska
<br />I .. AESIlJE~. STATE . ill cou~n
<br />
<br />, Nebraska I Hall
<br />
<br />Ie iNSIDE CITY ~"'TS
<br />
<br />,,' ~ATHI!ii. NAil[
<br />
<br />.. MIDDlE
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<br />Yo. Iil No 0
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<br />'0 RACE -le,g. w..., BAait:_ ..~ ~
<br />.,'s-~IWhite
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<br />)1'. NwCESTAYi.g ~"'lItt.A/'l.a..m...*1
<br />ISlloo~' American
<br />'e KINO OF IlUSlNESS INWSTAY
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<br />'3 ..AMEOFSPOUSE ,JI_~_"_I
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<br />,.. uSU....OCCUP'TOO~ ,G.._(II__~_
<br />""~.lIl9"".-n~"""'J
<br />Home Maker
<br />
<br />I'IIST
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<br />Domestic
<br />v.s~
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<br />
<br />17 MOTHf!l
<br />
<br />1.I4IOE" SIJAI<AUE
<br />
<br />. .. . . _Alfred . u
<br />- II WAS DECEASED EIIEA I~ uS _0 FOIICeS'
<br />'Wa"" "-I in '/8S. g............ "'_I
<br />
<br />'~I~~ M~~~EM
<br />
<br />King
<br />
<br />Dorthea
<br />
<br />Davis
<br />
<br />Charles Russell Phel s
<br />ISTREET OAIl.F D NC),CiTYOATOWN. BTATE:zIP!
<br />
<br />1615 North la lor Street Grand Island Nebraska 68803
<br />20 _ ._TUREH NO 2'e IlETIlODOFIlISfIOS/T101'< 2lD, DATE
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<br />2'< CEurTEIlY OR CAE"""'" ,,~
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<br />Not Embalmed Oa.... 0-..
<br />..:h. FUNfIlAl. HOIIle . NAYf
<br />
<br />Apfel-Butler-Geddes I]I~ OllcMr~
<br />_ FUNlIlAL HOME ~ ISTAEET OA A.F,D. NO CITY OA TOW" STATE. 21PI
<br />
<br />12-24-2003 entral NE Cremation Service
<br />21G CEUETflly()AC~E"'ATOAY~ ATOOf< CII.OllTQWN STAlE
<br />
<br />Gibbon, Nebraska
<br />
<br />1123 West Second Street Grand Island. Nebraska 68801
<br />23 _OIATECAliSE IEN Ell ~VONEC~US<PE"UNiFOR'., 'DI.~NDlolI
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<br />· -::~m~J eiX' \.~....,
<br />IDI \ N.~ ~~
<br />evE TO OR AS . CONSEOUENCE OF
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<br />EU""'EA OIl COAON{o'
<br />Yo> U "" n
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<br />STIlUTOAAFD NO
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<br />~:.,.v QC.!("J'Mt. sr,lTf
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<br />27a OATE a: DEA1H f~ 0... VI I
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<br />28a DATe: ~D t4fo ~~ Yr I
<br />
<br />! 28D TIf/IE OF DEAT..
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<br />December 23,
<br />271> DATE 5lGNEO tWo 0... ."
<br />
<br />2003
<br />
<br />
<br />December
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<br />24,200
<br />
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<br />...
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<br />28c: PAONOUNCED DEAD ..... lNI', y, I
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<br />ClU5ef51 SIIJIId.
<br />J~JIIIIT.I. ----r-t:
<br />2iI 0Ib TOB.lCCQ US( COIITIlIRUTE TO T
<br />DYES ~""
<br />
<br />D .--IOWN
<br />
<br />30,1) W"SCOfGf"T~'ED"
<br />DYES G 'C)
<br />
<br />Dr. Tari Mubin 800 North Al ha
<br />32. AEGISTIlAA
<br />
<br />
<br />Nebraska 68803
<br />:JlD DAn F..ED !y AEGIS'...... 1M> n.. '"
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