|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTN,fEI~(T, p~~H~ALTH AND
<br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF TP.lE,OE~F~I`jVAL !~"~L`ORP pN
<br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERi%IC~S,,•CIdT,JEfr,'~E~ORDS, '
<br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS ~:: ' «` . ~ '
<br />DATE OF ISSUANCE
<br />(] (~ [[rr ST.ANI~~' ' DOPER .
<br />MAY 1 5 2009 ~, O O 9 O~ 9 V~ ~ssrsrANT STATE RE~L$TRAR
<br />E~pAfjT~1ENT OF HEAL:~7`'1 AND
<br />LINCOLN, NEBRASKA HUIKA'~'IS~IR-/ICE$`. ', ;, -..
<br />ST/!1'E q~ A9l~ - D~/1F#7!I~iT s7iF F~~l1l.'fi$ ~ - is
<br />~•..~~
<br />~•.T_ ~T MIDDLE LAST ...•..~.~? SEX pATE '.]F DERTFf rAiar+'; L'M~, Y~.•rj -
<br />r~ A~gu~t voecks Male ~ebxca~x„~.. ~ 193 _..._ t
<br />' r++nor at u. Arey . ~avyJ ' Sr. AaF • Lkit ewrrdey ~ •: ~Yr CF BrRTF1 fA,br~,, oqy. Ydrrl .^ -
<br />(Y1>t1 SR tAOS. DAYS X. r1C\iRS~ MAYS.
<br />
<br />rb. FACFLJTY - NRma pP na . pN a1~M anP +WadAl
<br />St. Francis Medical Center
<br />ra ~SIZ>ENCE ~ $TArt, ~~ . ib. r'
<br />Nebraska Hall
<br />90. MACE • h-B., WtMMI, alre#, AiNUigrr YepNn.. 19. ANCESTRY Ir-s.A
<br />rya rsP+Q•rr rsa.~lrr
<br />~l1 t? ~~' xC~ln
<br />9 ar. USlIIA OCCUPATION jOlY1 >aTIR N wMl! dorl r /ndp
<br />d rrnrrmp zi.. swn a r~rdl
<br />Sales ~~~'
<br />FL u; tk Car°1
<br />t0. vrAS DEGEA,SED EVER w L!.8. ARME1~ FORCES7
<br />(T~, na, a wrk.l Ip r•r. Ow+ ww red drka d twicar)
<br />X30
<br />2W. BURW, G'Mllrlrble,Rrle~/r1. 27b. DATE
<br />DOgrlhn
<br />tion Febrt~ar ~, 1
<br />E9 - SIGNATURE t LICENSE N .
<br />~'d~
<br />PART!MMED CAUSE IEWTER ONLY(
<br />' jP h'~
<br />DUE 70, OR AS A CON CAi~iNCE QF:QF:.
<br />.~~cL~ ~~
<br />D'JE TO, OR AS q C~~Oj]HSEOLIENGE OFD
<br />ecl J~/tl jG~.d/'~
<br />PAR7 v ~.+en ,arumrn.wn c ~,urruv r runs - ~:orrpnrwra camr~ng to 9arle dui noI eplrYrd
<br />If
<br />ie. ACCIDENT', SUICIDE. FIOMIClDE. t1NDET.. 2EF,. OATS DF 1NJl1RY (Alo.,Ory, YrJ
<br />~r, aENDING INVEST>QArKxI f~P~+MJ
<br />coo. nuunr re r wr.mne 2d. PLACE OF INJURY - At home,larm, Nreat, frstpry, 12rSq. LOCAT'FDN STREET OR R.F D. NO. ~ CITY CR TOWN STlTE
<br />iSAr=My Y~. d Nal MKce truik4ng, etc. (Spac/11'1
<br />~~-2711. DATe OF DEATH (Afp.. DAy. Yf.J f Zap. DAVE SIGNED llliv., qry, YrJ (1tlS. TMIE DF DER.rH ~~-
<br />~--fir -~~ { - , , -
<br />a ~ ~ - ,. _
<br />2m. DATE 81ONED larz., Gsy, Yr! tie. TIME of DEi1TW ?!c. PRDNDUN(,ED DeAU (:Nu., n+Y. Yr.J 2BD. PHpNOUNOEa DEAD ~%weui~
<br />a ~ 27e T. o rAr wet a} my ranua~adryp. daAr rrrpd at dre tig4. dace and dw tPw '~ ~ 2&r 6n rr Mus d axammarnn rnc: a ,ms~rgrbon, m my oprnian artll occur. rC q ~~_ i
<br />carNal rtwd. I m 9rf prrra, dar and p+rcr rnC dua 96 7rs cruaNal aSrlyd.
<br />o and TN/e I ~ J~ ,
<br />29- 010 TOBACCp USE CONTRIpt1TE,'TO THE DEATH? ~:t a±tl T~ - -T~ r_
<br />~,~j~ f HA5 DRgAN OR TISSUE DQItiA~TION 6EEN CDNSmE~O? 3f)b. WAS GDNSENT GRANTEm
<br />C] YES f7 UNKNOWN d YES ~~~~ : YE5 ^,i1G~ ~
<br />91. gAME AND ADDRESS 4F ERTIF~p (PRY DROVER'S PHV8ICAN OR COUNTY A?TDRIUEr1 !Typ. nr anri -
<br />I3r. Ga et 'er 8 ~Ioward Grand Island, NE 58303
<br />32r. REGISTRAR 326. DATE FILl;D 6Y RE..;+5TFtAA (afp., ifyiJ''ey, Y,-.l
<br />""- ...=,,,~ Tom:: ( ~_..-..~.._ _ -
<br />r
<br />~. ~ ..A -~- ~ Jctl• ~ 2t~ ~ 19G2 -
<br />DEA"'r
<br />11D6FITAL ~ arprWrr! C EP•!~+eyZpe4Wl! a OGN
<br />ScL CJ Huang ~ ^ Rrnidrnca ^ Ollw rcpscgy) ~ - -^~_~~...-._ _
<br />9c. CITY. TOWlf OR LOCATION ~ DEATH ~ !d IN91OE CITY LIIYeTB-~y ~ pEy~ ^^^" :
<br />Grand Island 5~es Hall -
<br />8c. Cm, TOWN OR LOCATlO,Y - 4d. ,~,TREE7 AND NUMBER 1lnchdwtp Dp LbWI ~-iMa1DE aT+'. WMTS '
<br />~ Fspeoy -'a a Ab{
<br />. lGtiand Island 4U6~ Zola [~ane 68S{) jYes
<br />irn, elaalcaro, firrmrn ae.{ 92. >.IARRlrD.NEVEp MJIRRIE4. 93. NAMF DF sP:x/sE /el.are, y.s m.rtrr nw~M
<br />{ WSDDWEp, DrvoRLeD rS7a/yJ -
<br />~ f~ married Leataa S. Schwanebeck
<br />Iat). KWD OF BUSthESS WIX157RY
<br />v '7t ~ ~ EMnaaary a SrnonGrY IU•ei) CWlapp 19 r a s•)
<br />,Auto/ImplemanC I3ealez` ~"" 8
<br />voecks ~____~____~ Mary Kathericie La~t'echt
<br />- r9, INFORi.IANT -NAME - MAlIaNp AbORES5 (srREEt GR FtF.D: ND., crrY DR r7WN. srArE. z1P!
<br />~.eona Vaecks X066 Za~.a Lane ~arand :':sland,NE 6S$03
<br />:. CEM7='fERY OR CREAAA7pRY • NAME mod. LDCATIDN CIrY Ofi TOVw~ FtATE
<br />PER LIME FOR ;al, fb{. AND iel!
<br />' OR TOWN, s'rATE, 2IP)
<br />Is~„and , NE 65~(,~.
<br />I hretrrr~l Drrart rIU drMh
<br />I
<br />I `l~r,~1
<br />' .-. IrrOarYrl hailrryYrfl petl dpaCt
<br />- ...._ ._-....--- I
<br />i MN~rvaf ClN~4r~ anaal rnd drW1
<br />i
<br />PART NI IF FEMALE. WAS THERE A 2a, ALRCixsY 25. WAS GASE REFEgRED 70 MEDICAL
<br />PREGNANCY w THE PA&T 3 MpNTHS'+ f$prpy Y(~a or>tbl 1 p(AMINER OPI COi~TfER?
<br />vra l7 No G ~ ! (~~' Ysu a Abl yy77
<br />1 -..- - LYO
<br />INJURY TrE. OESCfrBE FiDW IN.fUF14' O~URf~p
<br />
|