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<br />STATE OF NEBRASKA <br /> <br />LINCOLN, NEBRASKA <br /> <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OFjjliA.LTI;f AND <br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE OR{Gl~jL,.Bt=CORO qN <br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICeS"vt:rJ.t"~f!~~@~,j; <br />::~::F ~:~:::;:HE LEGAL DEPOSITORY FOR VITAL RECORDS. ,.:', .c~:"" ..\It,'~. <br /> <br />S.rANLEy'. "DOPER , '.., <br />ASSiST. ' !s.TAitE Il"EGISTRAR <br />d&A..R ,nrdi=:tlEALtH:ANd' <br />HI:!MAN SERVICES' : , <br />'" .,.<' I <br />., .~>:2>:)' ,:.; ,\ ~L: ,\ t ,~C'; , <br /> <br />MAY 0 7 2009 <br /> <br />200903667 <br /> <br />PBs-'i08(VS) REV. f-57 . . <br />DBPART1IIENT OF PUBLIC BALTB. <br />mUCATION AND Wl:LFAllII <br />B~ NO. 128....000. <br />I. II'I.AO ., ......... <br />.. t.:ouNTY <br /> <br />Hall <br /> <br />, STATE OF NBB&ASU <br />DEPARTMENT OF IlBALTB <br />Bueau. of Vital Sta... <br />CERTIFICATE OF DEATH STATZ FILl'; !(O-...-.......--.._....__.____................ <br />t. .-u. - (..._--.. ....."............ ____.....__...,.) <br />J .?.s s .. STATE JJ6br. 6. COUtITY JLd1 <br />~. U~'rH OF STAY Iff ,16 t. CITY. TOtO. 011 LDC.\11ON <br />1 clq Cdre <br /> <br />S~li" 08082 <br /> <br />, <br /> <br />!l. ~iiY. TOWN. OR LOCATION <br />GrandIsls.Dd <br /> <br /> <br />.. 'STIIftT AOOMSS <br /> <br />'I~ NAU-M ' <br />:=:'-l::-: st.hanois Hoz;pital <br />t. IS l'LACE OF DEATH INSIDE CITY LIMITS? YES NO <br /> <br /> <br />3. ..... Of' <br />KCUUD <br />('I'r,. or prl.J~ <br />5. Sf X <br />maie <br /> <br />JlfUk <br /> <br />Let <br />Orndott <br />.. DATE af' MTH <br /> <br />f. 'A.. IlESUlllICil YU <br />110 <br />DfIf v_ <br />15 1964 <br /> <br />j:~ <br />. <br />4:~. <br />.r <br /> <br />EdWard J Orndoff <br /> <br />15. WAS D!CEASl:D EVER IN U. S. "~MED 1"OftaS? <br />(r... _." "d_l (II.... ..... _ .. _ '-J .....1 <br /> <br />0l'lVMTY <br /> <br />$TAn <br /> <br />i. <br />j <br />" <br /> <br />I <br />1 <br />I <br /> <br />z <br />o <br />~ <br />:5 <br />c: <br />j:: <br />e <br />g <br />25 <br />w <br />z <br /> <br />~ <br />'fU O'JiDZ--- <br />