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<br />WHEN THIS copy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMAN:a/!:lMCES
<br />SYSTEM, "CERTFlES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOtWPiiNMrM
<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA TISTIC, eGJfORiWHlOtl.,.o-.
<br />
<br />:::~:::::::~TORY FOR WTAL2REOCOOR8DSt" 0 3 .. 3. M. .~ _~::~.d~;It~~~;.~~:fl
<br />,JUL 2 8 2000 ~ )Vl,Nr'ffJANlai'h:s.~DgEIt? [~
<br />ASSISTMI'F6TA TEREGISTRlJt4i:l
<br />LINCOLN, NEBRASKA HEALTH ANtJHU~ SE~VlJ;J~ ~;'fJrt"f ~7
<br />
<br />STATE OF NEBRASKA- DEI'AR TMENT OF HEAL TII AND HUMAN SER vI6$>Fm~NeEifflRjj;JP~'
<br />VITAL STATISTICS":; . , " -o-,-.5~-
<br />CER TlFICA TE OF DEA TH-~o:;~~~
<br />
<br />i""j""()(c205:ii'..-N"A-M"r"-.''. -----.--~~.~_.,-------". 'v1i()ril"F-,,_.___n --.----1..A~1 _noo i :J ,;FX '-'-TJ6A.i"l~'.;).~.6[!~"r';-.". 1/>, \",I,V
<br />I Darrow Melvin Sems I male' July 22, 2000
<br />
<br />h-~~:~~AT~;~I;~d';'OI;~~~~~~~~~I--------r~~~ L"~-~,",Y",: ~,~~:ER' y~:~s -:, H~,~~:~R I O^Y 6 O~~~~;~;"'h;'7 ,"'d'i916
<br />
<br />TsoEIAl. SECURTIY NUMB~H __.___.__.~"..'d~_"__"_" - ---.... 8,3 Pl ACF OF f)FAf'H . ..-----..-----..
<br />508-05-9860
<br />
<br />HOSPI rAL
<br />
<br />I}(J
<br />D
<br />D
<br />
<br />DOA
<br />
<br />D
<br />[]
<br />[J
<br />
<br />01HLH
<br />
<br />NurS111q !!:l
<br />
<br />In~);:lM~n!
<br />
<br />
<br />"8b""FACll tlY - Nilme
<br />
<br />{If not institutiOrl, glll(J sh.....~1 JO(lllllmoerJ
<br />
<br />ER Ollt03tienl
<br />
<br />~esld~r\('('
<br />
<br />Francis Memorial Health Center
<br />
<br />St.
<br />
<br />Olh~' ,Spel III .. .__...___0_________.___ .
<br />
<br />I
<br />- -J 80 INSIOl; CITY LIMIT S --.
<br />
<br />'-'"-V~, G9 N" D
<br />
<br />,.--...-~~~ORL6CATIc)N' 9d ~1;l~'^~~~M:En~i'~;g.?(C~~X_~~;..:~D~~YN~'M5
<br />
<br />11. ANCESTRY reg Ila.llan. M8~lcan, German. elc;1 D W1DOWEO 13 NAME OF $POUSt: III wtl!) (JlVtJ mal/Jen rJ('lmel
<br />
<br />{SpeClfYI American OlvORCED Maxine Liedtke
<br />
<br />~- --F KIND OF BU5INf.SS lNDLJ~..,rRY ~1_~._I;DUCATlON ISpeclty O(")ly nighest g~~.?~, c:r.lr~:;;i~;';d~-""
<br />l,_.,Manufacturing "f''''''V 01 Second", '0 I?', COlleqo" ,," .,,,
<br />
<br />MIDDlF- ---- --~ -~--117 MOrHEA FIRST ~-~"'"MiDC.il[---'--MAlnFN :~UHNA~--'.
<br />
<br />Henry Sems ~ Elizabeth Caroline Packer
<br />
<br />_.~"--~F().RMANT NA-~-----_.~_.'~'- .,_.
<br />
<br />Maxine Sems
<br />
<br />Grand Island
<br />
<br />
<br />SC-.ClT" TOWN OR LOCAtiON of DEATH
<br />
<br />COUNTY OF DEATH
<br />
<br />
<br />9a, RESIDENCE - STATE
<br />
<br />Nebraska
<br />
<br />
<br />elcI \SDOCdvl
<br />Whl.te
<br />.~~-
<br />14a USUAl.. OCCUF1ATlON {Give kind Of work tJQtl9 dtJ(lng most
<br />M~~~Ittff~"ti'ec'
<br />
<br />16 F"ATHFR - NAMi::
<br />
<br />FIR$l
<br />
<br />Charles
<br />
<br />'8 WAS DECEASED EVER IN LJ S. ARMED FORCES"
<br />'v;;; Ol,:J :II ye'. q"e "''' ,nd d".' ", ,0",cosl
<br />
<br />19b INFO~MANT MAILING AOCll=lESS
<br />
<br />;'s'r'REEr OR I=lF 0 NO ICITY OR TO~WN c;l"Ll,TE. ZIPI
<br />
<br />203 East Pine, AIda, Nebcaska
<br />
<br />68810
<br />
<br />20 E:M8A.i.'MER. SIGNAT\JRI: & L1CEN-S.E'N-6---~" .,,,
<br />
<br />:2ia M!:THOOOFOiS?OSlrlON !Z1b DATE i ?1r: CFMF.TE,RYQR'(:R~'~AA:.'~':!~lY-N-AMf.'-.--."-'.'- ". .--..,----------
<br />
<br />D Bu,;,1 D R..,,,,,,, _~~l Y 24, 200'l__~~~t~~l Neb.Eas~~ Crematic
<br />21d CEMETERY OR CREMATORY LOCATION CITy ;:Ifl TOWN STATE
<br />
<br />Not Embalmed
<br />
<br />22a. FUNI;RAL HOME - NAME
<br />
<br />Apfel-Butler-Geddes
<br />
<br />[8. CremB:lIon D Don~II()1'1
<br />
<br />Gibbon, Nebraska
<br />
<br />2:11> FuNERAL HOME ADDRESS
<br />
<br />ISTREET OR RFD. NO CITY (lR TOWN. STATE, ZIP,
<br />
<br />1123 West Second, Grand Island, NE.
<br />
<br />68801
<br />
<br />
<br />,ENTm ONLY ONE CAUSf pER LINE FOR lallbl ANO lell
<br />
<br />~'\G'1'--'
<br />
<br />It'ltcf\lal between on5!;!1 ~ntJ (J(',1ll'
<br />
<br />23 IMMEDIA TE CAUSE
<br />PART () \
<br />I 1'1 r LLI..;v:J,.,
<br />DuE TO. OR AS A C(lNSEOUENCE OF
<br />~ C Cr--- V-- u.......-
<br />
<br />Ibl
<br />
<br />9~
<br />..,~ ,-
<br />Inlerv'll between ~>r1sel d"'d OCi1H'
<br />
<br />. ~ L{ ~~
<br />
<br />-'~--~~~_._---'~~ihAlw/;l'e!"1 C~1set ;~"r.lI1r:am -""~~-,..
<br />
<br />~D-i :"F.w~ OR AS A CONSE~UENCE OF
<br />
<br />lei
<br />PMH orHE:i=I SlGNIF"ICANT CONDITIONS - Condiliolls tonl1itJuling to the death but not felaled
<br />
<br />"
<br />
<br />
<br />125
<br />
<br />N,,[]l
<br />
<br />PA~T 111 IF FEMALE:- WAS THERE A
<br />PREGNANCy IN THF PAST] MONTHS')
<br />D
<br />
<br />WAS CASE REFERRED TO MEOICAI
<br />~)fAMINER OR CORONER"
<br />
<br />Ve:', 1'1 No .~.
<br />
<br />D{V\
<br />
<br />C..-o P D
<br />
<br />
<br />Sf A) t...
<br />
<br />2f.i~
<br />
<br />i 26b DATE OF INJUHY MiJ
<br />
<br />Day Yr J 26t HOUH OF INJURV
<br />
<br />[\
<br />U
<br />o
<br />
<br />A(.cloem C'=J
<br />
<br />UndelermtnE!d
<br />
<br />S''''-,Oe C
<br />
<br />v tJR TOW"~
<br />
<br />P?nOlnq
<br />
<br />26e INJURy A r WonK
<br />
<br />HmTlll;:lde
<br />
<br />ir1'vp.SI:gahon
<br />
<br />Ve, [] Nu [J
<br />
<br />..-. 27i'1-0ATF OF Oe:ATH (Mo. Day. Yr.)
<br />July 22, 2000
<br />
<br />15<<
<br />~g
<br />t~ ':.
<br />u{5
<br />~J
<br />
<br />29
<br />
<br />
<br />30.0 WAS CONSENT"'GRi\N1~---'-'"~"-------
<br />
<br />D YES
<br />
<br />D NO
<br />
<br />31
<br />
<br />Steven L.
<br />
<br />Grand
<br />
<br />NE. 68803
<br />
<br />132b
<br />
<br />I
<br />
<br />DATE FILED 8Y REellS l'AAR (Mo" Day YrJ
<br />
<br />JUL 272000
<br />
<br />32a REGISTRAR
<br />
<br />LEGAL: r,ots Three
<br />in Block Thirteen
<br />Hall County,
<br />
<br />(El/~) of Lot Five (~)
<br />the villaqe of AIda,
<br />
<br />( 3)
<br />(13) ,
<br />Nebraska
<br />
<br />and Four (4)
<br />Clarkson's
<br />
<br />and tne East Ha~r
<br />First Addition to
<br />
<br />m
<br />~
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