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<br />STATE OF NEBRASKA
<br />
<br />'"
<br />"
<br />
<br />M,\.I.."'.,:i.-.,'J......,'*" I:. ,:-~ ",')~:,:
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMiitl'r 9Fl.tf~Al,.iT~-:Artc, .
<br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF TH..:6~11VAL.-,IJ.ECqw.O:?>,M J
<br />
<br />::::~7::::::::i~gE[~::::1%i'70~~ 7g:L:;:tg,~gZ~Z. S~Rvn"'V~~';M' '. ;
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<br />:S@1~LEY. . 1;)(#E&:....: ;;,'~>
<br />YJ.SSISTANT STATtikEGtS:r~Ro'"
<br />bE1tARTM'f,IyT OFIj{f.JT,1:i /jjI1),'"
<br />Hv,MA,N,?~~~qfi.~:;~;:~, ': ";\~~';.
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<br />
<br />APR 0 9 2009
<br />
<br />200902764
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />1. OECEOEMT. NAME
<br />
<br />STAtIlOfNEUASKAoDEl'AllMENTOFHEALlHANDIMwiSEllVJCEs. fDlANCtAND~.. .'
<br />. . "VfTALSTAmncs > 0 j
<br />.CERTlFlCATEOF'DEA11I ' . '.
<br />. '" IllE . L4 T aSE' '" llATEOf DliATH ,_llw._
<br />
<br />
<br />. .. .
<br />
<br />10140
<br />
<br />"MT
<br />
<br />Boise, Idaho
<br />7. $QQA1. 5eCUR11v ~uMBJ;:A
<br />
<br />
<br />Female
<br />UNDEJIl1 yEAA ONOfR 1 DAV
<br />511. MOS. Dl\Y5"", HOUll5 _8
<br />
<br />
<br />1 26
<br />
<br />4. 'y~1\fD AT OFBlRTH ,."",.,U.SA.~~
<br />
<br />.. F4CIUTY._
<br />
<br />""'_"'---
<br />
<br />eo. !'LACE OF DeAT~
<br />~~,'O-
<br />o ER 0uIp0IIenI
<br />OllOA
<br />
<br />. ~~ ,0 "",-_.
<br />~~I'IC:.~
<br />0..,...."",..,,,,,,
<br />
<br />431-40~8884
<br />
<br />323 Stub St.
<br />'" CITY TOWN OR lOCloTIONOF._TH
<br />
<br />
<br />...
<br />
<br />Nebruka
<br />III COONTY
<br />
<br />''''''''-4>C_,
<br />
<br />
<br />v.O...1LI
<br />
<br />Doniphan
<br />11. ANCESTRy Ie 9.-..... .....IC~. Gmnm._)
<br />1500<1'"
<br />
<br />13 NAMe Of" SPOusl
<br />
<br />Homemaker
<br />
<br />Richard W.Bass
<br />..-
<br />eo.g.l1.COfS'1
<br />
<br />,I. FATHER ~ NAMe
<br />
<br />. FIRST
<br />Hugh
<br />
<br />MIDOL€
<br />
<br />MAlDE" SUIlllAME
<br />
<br />R.
<br />
<br />J.
<br />
<br />Schoonover '
<br />
<br />'1. WAS DI;CEASEO evER IN U.5. AtM"D FORCES?
<br />(Yti, no. 01' ~,J /tIyn._gI"Jtt,'IIdf.-.fdAtKallltf\llCMl
<br />NO
<br />
<br />19t1 tHFORMANT
<br />
<br />YAlllNGi AOO-=lESS
<br />
<br />PO Box
<br />20. E"'B"L.YEJil ~ 5IGN~ruMe.Il!Ca.sE NO
<br />
<br />I 2'Ic CEMETERY OR CREMATORY NAME
<br />
<br />Not Embalmed
<br />2Z. FUNlJifAl,. WOME + ""...e
<br />
<br />0...... 0 ....""., 09-04-2003 Central, NE CremaUon Service
<br />~tcJ ceUEll:RVORC::Flf:~Tot:lYlOCATION CllyORTOWN STATE'
<br />
<br />Apfel-Butler~Geddes F.H.
<br />
<br />l.!l-- 0 ~~...
<br />
<br />Gibbon, Nebraska
<br />
<br />m. FUN~ll4OMF.: j,OORESS
<br />
<br />fST~EET Of' RFU NO CiTY OR TOWN. ST,ATE. ZIP)
<br />
<br />
<br />St.
<br />
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<br />""'vat ~onH'l.n(I oeD!
<br />2--""''''~/'
<br />
<br />"""1f.1 bttWMn cnMIlno otMn
<br />
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<br />Oui: TO. OR AS A CONSeOVE.NC:~ OF
<br />
<br />tnt.rvalblllwftnonRta."1d~
<br />
<br />r"
<br />PART OtHEA StGMtt(:AN1 CONOfTiONS . ~, ~nalo me~ bUI n(II!,~
<br />. .
<br />
<br />I
<br />
<br />
<br />.. _ one OF lNJlIRv [I.fcJ. ""..-. Yr.J 26r. HOUR OF INJURy
<br />
<br />o Ac<_ 0 ~-
<br />
<br />o SUit" 0 Pe-~ 2de JNJuAv.'" WORK
<br />0-...
<br />
<br />ze. DATE SlGtIIED /Me O~" YI!
<br />
<br />:lib T1U'EOfOU1H
<br />
<br />>;h I
<br />J!~~
<br />.~n
<br />
<br />..
<br />
<br />28c "~NC~[) DeAl) IA.~ ~y, )",}
<br />
<br />280. PRONOUNCED DEAD (HourI
<br />
<br />..
<br />
<br />..
<br />
<br />XJ b W"'S CO~SEJft GAAt.llED"
<br />DYES [9: "0
<br />
<br />Gordon Hrnicek,
<br />;J2a REGiSTRAA
<br />
<br />Grand Island, Nebraska 68803
<br />:Qb 0,1, TE Fn.Eo BV REGISTRIIoR IMA. ~r, Yr.J
<br />
<br />SEP 1 0 2003
<br />
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