Laserfiche WebLink
<br />STATE OF NEBRASKA <br /> <br />! <br /> <br />.. <br /> <br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF '1cE~L,TH,AND <br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAt. 'R~COR'D'~N. <br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES(.;.tIfr,\~<::~.Ed~'RD~ . . <br /> <br />::;::F ~;::::;ETHE LEGAL DEPOSITORY FOR VITAL RECORDS. aa:.~.. le, <br />FEB 2 7 2009 2 0 0 9 0 19 4 0 ~~~1i~:NT;s$Ac;e;,E:(j~t~~RI" :. <br />DEP,tf[rrMENT OF~HE".UrJiAi;i:Cx/ ; <br />HUMAN 'SERVICES,'..::~" . ,: (::;. . <br />I . (.' ,~. ::',:,/"JY:l\~.";L .~;~; . <br /> <br />: j '~. i..r" ..... 0"" J 'I' I~"~ ..I. . ,"'\:u ...,~ <br /> <br />" i:<? 2 '':-:1167 4 <br /> <br />LINCOLN, NEBRASKA <br /> <br /> <br />ITAU OF 1_1lUKA - D!PAR'1'.-n" OF HEALTH <br />MlIIIMt OF VITAL ITA1'IP'XI <br />~.~TEMDlATH <br /> <br />~ ,. I <br /> <br />..... <br /> <br />FIIIIT <br /> <br />umllL.I <br /> <br />WT <br /> <br />:lID <br /> <br />Arvon Rodger <br />lIT" T1i OF IIIlTM ,.,.. ill USA.. _ '*""YI <br /> <br />Jensen <br />lie. _ . ... ...... <br />~. <br />73 <br /> <br /> <br />St:.. Francis Medica.. Center <br />. STA ... COIJNTV <br /> <br />Grand Island <br />to. .....___~ ....vasTlIVje.g_._~...) <br />....~e ~~ican 01- <br />,. lJIl.W. ~ATIClIrI"" _01_ _....,_ <br />01.....,... _11-" .) '11, ,,\ \ <br />Farmer "\ .. ..., <br />... FA . IlAME FlfIST umDI.E 17. YOTHPI . IMIllil!Jj _ <br /> <br /> <br />Grand Island I <br />to. CITY. Tow.. OlllOCA TIOtl <br /> <br />~o?bD <br /> <br /> <br />-............... ' <br />12th ' <br />FlIlST IIO!lI..f <br /> <br />c... i1.4 .. M <br /> <br />IA1" <br /> <br /> <br />Alfred <br /> <br />Martha 50censen <br />lIIT'IIIET 0lllU'.1l1llO.. CK"<f O-~. tt.'lYE. a-t68803 <br /> <br />Jensen 4213 5 1eman Rd Grand Island I _ <br />l;QoIfTEI'l1 O'l~TOIf(L..~__ t . ... I.D(:ATIOIIl CITY 011 ~ ttAIE <br />rt~ra.l l'EDra8..a l.Tema . ~on <br />rvice Gibbon, NebI:'aska <br />~ F..-, ~ . _ MO ~ lflT1EEI 0lII1U' 0 Il1O.. CITY Oll-'tt-'l'l'l. "'" <br /> <br />fe1-But1er-Geddes <br />~ OOL y (>\. ".......~,. LIfE FOI'I '.. IIlI. 1WD !eN <br /> <br />L.;, "'~ <br /> <br />1123 W 2nd Grand Island, HE 68801 <br />-"---- <br /> <br />------.- <br /> <br />-"---- <br /> <br /><mtI!A ~~. c:o.-.--.gllo _ b<lI"'_ IPAlIIT. If' FEMALE...... TI4EAE A <br />,.~ \, l) \" '" _OHA/C( IN YlE PAST 3 UOtf1'He'> <br />... \...) . .v '1M 0 Ijo D <br />... ~, ~ IIICMCU. UIIlXT.. .. DATE OF IIUJlIlY il',:~o." Yr.J 2tc. >O..IA OF IN.IUIIY .. 0ESCAIlIE HOW INJt.iflY 0CCUMf0 <br />OR ~ IlM;lIllQA"fJC:* /6I>>djtj <br /> <br /> <br /> <br />a.. ....."" AT_ <br />~y...1JtIj <br /> <br />STl'IEET OIl Rf.o. NO <br /> <br />CITY OR T(MW <br /> <br />tTAn: <br /> <br />... OAT!; lIIONl:O ... Dey 1") <br /> <br />_ _ 01' DUTH <br /> <br />}s!i. ae.~~ _.o.y.'I'} . .*'~CIf.oo_; <br />L~ <br />.IIi I <br />~ s ... Oft.. _.. _ _................... _ _ _. <br />. ....-.-----....-- <br /> <br />. <br /> <br />,- -~~ <br />I <br />I <br /> <br />~ YES <br /> <br />.~~ <br /> <br />_ AIE~ <br /> <br />3a. DATEF.:.Eo....~ --010,; "'} <br /> <br />OCT 7 1392 <br /> <br />I <br /> <br />~- ~ <br /> <br />.'-..) <br />, <br />.,' 11"'-.., <br />; I_.~~ <br />Page 2 <br />