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<br /> <br /> STATE OF NEBRASKA <br /> <br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMEN'ix~P"fiE~JAtiTp AIU.; <br /> HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE, ORI !fW f ~t Q),bN <br /> FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICE & NITJAL• RE[f 1 Y <br /> OFFICE, WHICH IS THE LEGAL DEPOSITARY FOR VITAL REGARDS. ~ r11~ <br /> c <br /> e <br /> DATES OF ISSUANCE 200903191 <br /> TRAR <br /> e1 FAA tM ('iOF,(~ ~~hri~Nn <br /> LINCOLN, NEBRASKA <br /> yB! <br /> HCT1F ICE' <br /> STATE: OF NEBRASKA-DEPARTMENY OF HEALTH AND HUMAN SERVICES FINANCE AND•SUP ) <br /> CERTIFICATE OF DEATM____ <br /> 1. DECEOENT•B,NAMe IRIM. M MiddM' Lw. sum.) _ 12. SEA ~ aGA QF pEA711.T1Ny. G.prrl f ~ <br /> Isabel_le_ Doris Pedersen_ Female A~eirT 2U <br /> 1. CITY AND STATE OP TERRITORY, ON FOREIGN COUNTRY OF BIRTH SA AGE•NII B+IBeq!56. UNDER 1YEAfl'Bc. UNDER'1 OAT B.D/TEOf BIRTH O'T.W,F 'I <br /> ;YU-) ~M06. DAYS NOVR8 MINS. <br /> Scotia, Nebraska 79 June 1, 1926 <br /> 7.50CMLSECuRITYNUMBER -----M.FIACE OF CEATN^~T~ --T_._, <br /> 508-98-0283 aDSpm; 2A I.P~t ODES ]N~NHWWLTC :)N%WOF" <br /> Mo. FACILITY•NAME' IN R211RmIwIPR. 9iv. APAN Ana -0611~1~•'^~ i <br /> Z) o.c.am E <br /> St. Francis Medical Center eRTAnoAbAM J I <br /> ~ Don ]On«ISOAxI•) --_._I <br /> 8F. CITYGR TOWNOF DEATH IIRAIAdn tW CAPA) 8d COUNTY OF DEATH <br /> ] <br /> d- T-SlA n d68HII3_~ MA I <br /> 9a.PESWENCE•BtQE "gCDuwIY (A•.CNYORTOaMw <br /> arand and <br /> K57METAWKWOER Be- APT. NO 21. ZIP CODE III INSWECCOYLGETS <br /> 2316'W . Louise. _6_8803 M Yes 'p NO <br /> 18a.MARRALSTATUBATTIMEDFDFATN MrMd']NAwimanim v0b.NAM6 OF SPOUSE IFIn1. MMMN~lAA1. 9.IIM)Rwde,pwn .dita-. <br /> 7L41AAd-bw 1APRIEMd uwwmd 70.w.ad 7unNRe.R Dale Pedersen <br /> II.FATHEITS•NAMF IFURL MAN., L.M. 8.110x) '12.MOTHER'S-NAME IF.A1. NOW., Maiden SI.RAreol <br /> Robert Smith _ _ Anna____ Wegner <br /> 13. IT ER IN U.S. ARMED FORCES? GNP dean. NAAIYNA H TAA.'IRA. INFORMAN4NAME 140. RELATIONNHIP TO DECEDENT <br /> Iry..RRWUnN.I No Dale Peders_en_ Husband <br /> vi METHOD OF DISPOSITION 'TFA.TJA NATURE -10_0CENSM.. 1EC.DAT[(09..Dmyyr,l <br /> )35.w UwACO 9 <br /> n 11, 2tl06 r <br /> 3C-fiFn ~f.11MI.6m.11I .1Bd.CENETERT.CREMATORYOR3TNERLOCAT CITY: TOWN . STATE <br /> ❑wmeNr . DaA.IIaPawl Mount Hope Cemetery Scotia, Nebraska 11 <br /> 1M FUNERAL 11CMENAME ANDMARING ADDRESS (SIrxl.Gry orTnwn. SMlel 170. by Cevv i ' <br /> i 5 f <br /> tB PART 1, ERlnMOlpl~yap~•y.FOxA..IRIrhA.sl:wlqulwlF-1Rn mYenTewfM+MMAA pp NOTOnN.prll.,nMnn9v A.AIUUrWAI: ennl APpRDNNaIEIME111rAL i <br /> Ny.AN.yAmN.aNMNN4rGM~IA:sn FARMA MIa1nq WAwAey)pp NDi ABRREI'NTE ENIreN/pn cewvA.eNIn AeD addAAIIAI NnnimeeANry ' <br /> dRMEONTE CAUSE 2nn1I.dAAm I' <br /> yet i4' ff~+tsrc~ ~e~~ _ , <br /> WM.MwrANwm.All~ OUR 10. OR AS A CONSEQUENCE OF nnNbdlAlA <br /> 11detwelk-H e", e- <br /> a".1F.iIEYN.IN.gPp.Nd DUETQ- BADONSE011{NCE OF. lLFS~r~ <br /> anW1.A. - awlbPMer <br /> bo rmetwO LMOAMRF <br /> 'MN.eAVWAeIIryEWIMRAIrd R) <br /> ~ow~ ~'ybB DUE TO. GRAS A CONSEQUENCE OF. <br /> ~ NMIPdnm <br /> RO <br /> 18. PAPTN OTHER 8IGNIFCMJTCONDIrMa-Om Ep *A"wft"am bm mire.WUp m mv-dArlyingampan In PANT I. TT12.wA31AEDICALE%MIIHEP .4L <br /> ORCORDNFRCONFACTEDT <br /> 7 TE8 )WHO <br /> M WFEMAIE 21, WIwAfROFqCEATH 'S1n1FTNANAP(INDNgNDFJDIry; 21cWA%AMAUTCIPZYP1RFGRYfD? <br /> YNNe.p.m•.mRgnYAA >i7NAaM W,H} JD-OpAnb <br /> ❑ <br /> h.q.Mx Al limeddeAlA 7AnpNgJ PO/A.IQ NwnyyMpl ]pandeegarTES KNO <br /> . <br /> NAlpnpuN.?mpASnerA wRnN A2 PFTFdd.am '7 FAFnn1Arl 21N WERE <br /> ALNQPBYFeAUV188AVAAASLETO . <br /> 78wPP. JCOUq.Np11.M11ninAd •7g4r(BPKNI) 1 <br /> Na1NPpNnL URpopnpoA7da)Aw1?urblNe tleARl WuIETECAUSEGFIDERMD <br /> 7 UnNRn.OwtrAmwM mpidayA.r _ 3 TE8 `ENO <br /> 27F. DATEGF INMD IN., Dry. Yr.) ..M, TIME On INJURY' 22e PLACE qF IIUURV•u Rene Mrnl MrAALIWery, eRKP bI.M.q, CFMVULNaIMM..N.IBPAnry1 <br /> j <br /> 2201NRRttATYg1Un ' 22A OESC111BEI{p1y gMURY OCCUPPED. W <br /> YES ]NO <br /> 721.LOCATMNOFnvAIRY-STRSET6NUMBER.APT. MG CRY1TCRN Sm 7F000E -..._I <br /> . ry. WE OF DEATH IMP. JN DATE SIGNED IM., Be,. Yr,r ~---yMe TIMFOFOMTN <br /> S G_- S M <br /> Pan. DATE SIGNED IIAR. DAy,YII 211.1IMEQFWA. ':2ME.FROMOUNCEDDEAD IMv.OAFW.) : 7NTBEppCIMOUNCEDDEAD <br /> M TO <br /> i m. NNNIIry NIewMOp.,YMAgpyr.dNWWM,tlAM Ntl EGO. Gn PIoMla dbuPN1ARNIAItl'a Bm.b d..menlA.M ) <br /> AM ro t+..AvIM1AMMa IMgMIIIn ugTAbfT/ ~ mnlwN. vAberA WAn omvuAb v'TnF~Iw1. <br /> ~ ~ INN.) NtlML (B)p1FAFr BnOTIp <br /> pi,(MDTp8AC0D1MEECDMIWWISlT1111S DRUM '2Y. HAS ORGAN OR TISMUE DONATION BEEN CGNBIDFNFflt 2B4WANCONSENT GRANTED? <br /> 7 YES NO PN08ANLT O YN1aMQWN TES NO 1 Mi'A AM. D Eh IF NO 3'YEB Q i <br /> MAME.mIEAtm ADOREBE~'~ EN IPNY91CM11, 1 R'B . RNEYI(rMw P"w . <br /> ft p . <br /> -94REDIBTRARBSENIMIWE , 1 sea DAn FRED NTRi,WrTUR IM2_Dey,Wa <br /> d. APR 18 zoos <br />