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<br />C~~ENT NAME
<br />
<br />FIRST
<br />
<br />STATE OF'NEBRASKA~ DEPARTMENT OF HEAL!H 200 Q 0 3 4 5 3
<br />BUREAU OF VITAL STATISTICS .,
<br />CERTIFICATE OF DEATH f. Lldu
<br />MIDDLE SEX DAlf OF DEATH (Mo., JOY, Yr.)
<br />
<br />. ., "
<br />r.::\.
<br />
<br />
<br />1. GOTTLIB
<br />RA(;E-(e'\I.. Whltr, Black, American ORIGIN/DESCENT(e.g"lIalian, Mexican,
<br />Indian, ek.) (Specify) German, elc.) (Spedfy)
<br />~. WH ITE_ 5
<br />--ClfYAND STATE OF BIRTH (II not in U.S.A"
<br />nome count,)')
<br />8. HALL COUNTY
<br />SOCIAL SECURITY NUMlIER
<br />
<br />If HOSP. OR INST. Indica'. OOA..
<br />Ol,lfpatient/lEmer. .m" Inpatient (Sp~ify)
<br />
<br />
<br />1~e. INPATIENT
<br />COUNTY INSIDE CITY liMITS
<br />(Specify,t.. or No)
<br />HALL 15<. GRAND ISLAND 15d. RT #3 15e. NU
<br />MIDDLE LAST POTHER-MAIDEN NAME fiRST MIDDLE LA
<br />
<br />POI lOr\( ill. FI T 7 ARFTH ROTH
<br />IIIFORMANT-NAME_ RflAT/ONSHIP-MA!UNG ADQ~~,?,s /S"~ET all F D !,ID. :;;1I)'.l:l.U.c"""',.~l.:.a, "'~;-,
<br />
<br />_ 15aNEBRASKA
<br />...- 'ATHER....NAME
<br />
<br />pANTONJA POLLOCK. WIFE.RT. 3
<br />CEMETERY OR CREMATORY - NAME
<br />
<br />
<br />BOX 6
<br />
<br />GRAND ISLAND
<br />CITY OR TOWN
<br />
<br />NEBR.
<br />STATE
<br />
<br />i..
<br />:!i
<br />"u..
<br />.!ii!g
<br />{~.;,:.,
<br />~a::~g
<br />a.M.u..?; 2~b.
<br />~~8 PRONOUNCED DEAD
<br />... 0 _ (Mo., Day, Yr.)
<br />23d~",.,__,Aug~,S~.,.,_..~~79 VO 2-4d.
<br />-NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSIC'AN OR COUNTY AnORNEY) (Type or Print)
<br />
<br />, Lincoln, Ne.
<br />
<br />rl
<br />19
<br />i~
<br />-x"
<br />J"r6
<br />Jl
<br />:f
<br />
<br />2lc:. WESTLAWN MEM)RIAL PARK 20d. RAND ISLAND NEBRASKA
<br />F JNERAl HOME-NAME AND ADDRESS (sn~ET 01 I.F.D. NO" CITY Ol TOWN. STAn, lIP)
<br />
<br />1 W. ~~~~~GI~~D? NEBR.
<br />
<br />
<br />On the bali. of .Jll.C1mination gnd/or In~.'lg(l'ian, in mv opinion d.ath oc;:c;urr.d at
<br />the tim./ date and pigc-. c.l"Id du. k) the c:au..(.) dot.d.
<br />
<br />2"0. (Sig~(J'c.rr. (Htd Titl.) .....
<br />
<br />E (Mo. Day, Yr.
<br />
<br />
<br />2~c.
<br />PRONOUNCED DEAD (Hour)
<br />
<br />101
<br />
<br />24.
<br />
<br />M
<br />
<br />
<br />DATE RECEIVED 8Y REGISTRAR (Mo., Day, Yr.)
<br />26b. SEP 6 1979
<br />
<br />.n..Ntll b.twe.n on..t Clnd d-clth
<br />
<br />
<br />Int.",.al b.tw..n on,.., (lnd d.-oth
<br />
<br />~ Intracranial tumor.
<br />DUE TO, OR AS A CONSEQUENCE OF,
<br />
<br />(Renign,mpningpomR)
<br />
<br />several mon,t'hc:
<br />'nt.rvgl b.tw..n OIU.t and-~
<br />
<br />(.,
<br />PART "eiTHER SIGNIFtC........T COp.,jDITIONS ~ Condition. c:ontrihu.ing to d.ath but not r.latwd
<br />II
<br />
<br />30.,
<br />
<br />\" ~~<;;.. J i
<br />. \".;. '. '1../. ,,'
<br />",,-,..., \,JI''''' ',',I 'I!.,.",_'lq..o, .\:
<br />,.. _,___~~.r'L'__j:>.'_,:l;:'-;", .. .
<br />" ~&.tr.A..~~.~$.i~(~~.",. ';~NiA~~I. ~~A~~~, R~~S~~R~~~iE~F T~:';-A~~~-~A~~A BE
<br />
<br />,-"/4 \XRtf~j 'P9t1....ot AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />;~~i:..~~~~~:P:~F- HEALTH, BUREAU OF VITAL STATISTICS, WHICH
<br />Ii~l.i,,"~".f:Mi:L' DEPOSITORY FOR VITAL RECORDS.
<br />, I) t i.~.Ji 1)\- "1,..01 JJ . .
<br />... . . <J~~&.cI
<br />DIRECTOR OF VITAL STATISTICS AND ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA TSSllPd September 28, 1979
<br />
<br />
<br />PAn III. IF FEMALE, WAS TH~l~ A
<br />PlEGNANCY IN TH~ PAST J MONTHS?
<br />
<br />WAS CAS~ ItFEUED TO MEDICAL
<br />EXMlINEl Ol COlONEl
<br />(Sp.t.i''1 'f.. or Na)
<br />29,
<br />
<br />ACCIDENT, SUICIDE, HOMICIDE, UNDH.. DATE OF INjUn (M... Doy, y,,)
<br />01 PENDING INVESTIGATION. (S,..c;"')
<br />
<br />30".
<br />INJUlT AT WOlK
<br />(Sp..~iI,. r.. or No)
<br />
<br />30d.
<br />
<br />snUT Ol I.F.D. No.
<br />
<br />CITY 01 TOWN STATE
<br />
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