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200810155
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Last modified
12/15/2008 4:11:58 PM
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12/15/2008 4:11:58 PM
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200810155
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<br />200810155 <br />STATE CF NEBRASKA-OEPAATMENI' CF HEALTH AN[)HUMAH SERVICES FINANCE ANDSlJPPCIRT 324367 <br />CEFmFICATE OF DEATH <br /> <br />.. DECEOfNrS.NAIIE (!'lll'. <br />John R FendeIwon <br /> <br />.. CITY AND SlATE Oil TEII"ITOIIY. 011 FOIIEIGN COUNTRY OF ""TH 5., ...OE.U.III....., <br />IY".1 <br /> <br />11_. <br /> <br />U.I. <br /> <br />sum" <br /> <br />'.IEX <br />M8 <br /> <br />:1.11IIIII OF DEAtH ...... DIJ. n, <br />Oc:tvber 31. ZOOlS <br />'.llATEOF"TH (lIt..Dor.Yr.) <br /> <br />RIsl C . NebraQ 76 <br />7. $lXW.IECUIlITY~" II. PLICE 01' DEATH <br /> <br /> <br />20.1930 <br /> <br />508-30-4751 <br />Ill. pACILlTY.N.....E "' nO! Inll"u...., gin .Ir... .n. nu,,"" <br /> <br />~, <br /> <br />1Il1n".'1II <br /> <br />lZHB [J ....._TC a......F.. <br />[J~._ <br /> <br />I <br />I <br /> <br />i- <br /> <br />f <br />. <br />. <br /> <br />~ Medal Center <br />II. CITY 011 TOWII CN' DEATH 1_ ZIp CoIAI <br /> <br />Om8ha 88198 <br />kllE8llEMlE.aWE <br /> <br />NMruIca <br />. STIlEfT NID IllJI-. <br /> <br />1405 weat StreeI <br />.... .....NlAL IllUUS AT TillE OF DEATH IIIl....H 0 N..., 11",," <br /> <br />o e~_ <br />OlD\ <br /> <br />o OIltrlSlltlllJI <br /> <br />lid. COUNTY 01 ClE...TH <br /> <br />H.II <br /> <br /> <br />... Z11' CODE <br /> <br />It. ... CITY uttlTl <br />II vel 0 NO <br /> <br />.. COLWIY <br /> <br />a ..........11III........ [J _ 0 llIYArcoM 1:1 Ut*r-.. <br /> <br />II. ""THEA's.NAIlE (F'"'' <br />K 0 Fenderson <br />':1. bEAIN u.s. ARIIED FOACEI? GIn IIln or _II,... '''.INJOflIlANT.NAlIE <br />Mo.... on....l Y. 03I11161..()311953 JOlItI M Fllndel1lOn <br />,I. IIETHOO 01' DlSl'OIlnON 1M. EIlIIALIIEIl-IIGIilI\I\IIE <br />Obol O~ Not Embalmed <br />1Ic.me... 0 ~ lleI. CElInERY. CAE.....1ORY OAOTHEII lOC"'TION <br /> <br />a,,_ OOlltrl~1 <br />EIrrIcn CrwMtory <br />l~ ~IW.ItOIIE NAIIE AND IWUNG "'DDAEIS :='1. CIty or'-!,SIIItl <br />IIOyd E. BtMIIIn Mortu.ry, 1702 N. 72nd , 0inI1'Nt, NeIWIlIQ <br /> <br />III...... <br /> <br />LI". <br /> <br />.10M M Roae <br />SUIltI) <br /> <br />'2.1I0lHE"'S.N"'IIE (FI".. 111111.. <br /> <br />Lollie C Deland <br /> <br />1I.lIon su_",., <br /> <br />'.b. AELATlONIHIP TO DECEDENT <br /> <br />CITY I TOWN <br /> <br />WIr. <br />'Ie. DATE (III.. 0.,. Yr. ) <br />November 2, 2008 <br />"ATE <br /> <br />'11. UCENSE NO. <br /> <br />Omah. <br /> <br />IilIblukII <br />."'.~, C... <br />.114 <br /> <br /> <br />Al'PRlIllIlATE ~ <br /> <br />-11- <br /> <br />_lICA_...... <br />-..-..... <br />.... <br /> <br />.....-....--.. I <br />.............-... <br />...... <br />,............CMIIE <br />............- <br />.._.....to... <br />... <br /> <br />III <br /> <br />tl1. S1 S1-c r.,f <br /> <br /> <br />I~- <br />.....- <br /> <br />~()\~ <br /> <br />.1 <br />DUE roo OR A'" CONSEQUENCE OF, <br /> <br />_Ie ..... <br /> <br />Ie) <br /> <br />DUE roo 011"1 ACONSEOUENCE OF: <br /> <br />-..- <br /> <br />III <br /> <br />II. MIlT I, OTHllRSlGNlFlCANTCOflDlTlONS-ConoI....-...gIO... _1IUt1lOI.........In "'1IIlII1lP'4 CIWe _..I'IUITI. <br /> <br />e. TillE OIIN.1UflY <br />III <br /> <br />"4 WERE "'UltlI'lY RIClINI3I AVAlLAaE TO <br />CDI'lfTE CWIIE (I' llEAJH'/ <br />YES CJ NO <br />UC.l'I.ACt lJf '"""AV.AI"'....""". -. _". ._ ...1...... __ ....Ie. (Ipoc:ny) <br /> <br />21b-IF TllANSI'OftI'ATlON IIUIIlY <br />Ollltw~'" <br />o ......r <br />0,,-- <br />OOlllfI~~ <br /> <br />10. WAS IIEIlICALElWllHEA <br />Oil OOIIDIIEIl COIlTACTEO'I <br />o YES ~NO <br /> <br />21e. WAS AN AUTOI'$Y l'EIlRlIlIIEO'I <br /> <br />C'YfM.tW <br /> <br /> <br />cU+t e;..-k <br /> <br />I <br /> <br />j <br /> <br />J <br />. <br />~ <br /> <br />20. F PE....U: <br />[J lIIl P......._. "" ,.r <br />a......"'..."..... <br />o ..............1luI ~....., oil .." II.... <br />a 1IIl---.1luI..........,.IOI,..,-...... <br />a ~ I'PIIlPlIIlI_ .......,.... <br />ztLIW10pIN.lUIlY (110.. Illy. Yr., <br /> <br />2 IL IIANtIilI OF DEATH <br />liIHo- CJ_.. <br /> <br />[J ~CJ "-III ""'Igdon <br /> <br />OllllClll a~IIIII"__ <br /> <br />)6. YES <br /> <br />0'10 <br /> <br />211.1MUIl'M'WI:WrI <br />Q YEI QNa <br /> <br /> <br />221. LOCAIIIlIl OF IIWll'I' . STJIEET & NUIIIlEA. AI'T, NO. <br /> <br />CIIY/DIlN <br /> <br />RITE <br /> <br />"'CDDI <br /> <br />;; <br />i <br /> <br />'p <br /> <br /> <br />ili <br />:1 <br /> <br />Z4L DATE IIGNI!D lllo..llQ. Y'.) <br /> <br />lID. TIllE OF DEATH <br /> <br />i <br />I <br /> <br />flli <br />=1' <br /> <br />m <br /> <br />:Mc. l'AONOUNCED DEAD (lIIl..llIJ. YI,) * TllEI'ACINOIlIlCEDDEAD <br />m <br />Me. 01'" _ II _..._............. In.................. <br />........, .......1IfIOt ..,..... ... c:outICl)..... (..~ ... --)1' <br /> <br />.--CONIIIfT1JlrAIITIOJ . <br />""' ""'_'" HI. NO CJ YEI 0 NO <br /> <br />ME 68198-3331 <br />"IWII'lUiD."~ I........ ftl <br /> <br /> <br />a <br /> <br />TRUE CERTIl='IGATlON OF <br />A RECORD OU F!lE '!11TH <br />DEe 2 t 70nfi <br /> <br />Ik- J Ju.r <br /> <br />REGISTRAR <br /> <br />vrr;,l_' TISTles. DOUGLAS <br />00. I1Etd...lH DPT.. OMAHA. Nl <br /> <br />::j:,~ <br />
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