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~~ ~ <br />~~~ <br />~ - ~~ <br />~- <br />H~~ <br />~'~ ~~ <br />.~ y <br />~- ~~~ <br />~ ~ r~ <br />~~ ~~ <br />~.w ~~ <br />~ ~ <br />t /i7 <br /> <br /> m <br />rn <br />= ~ r.~ ~ <br /> <br /> ® ~ ~ <br /> ,v <br />,,' ~ ~ ~ ~ rv m <br /> c <br />~' ~ ~ ~ A <br /> 2 r c> <br /> a 4 <br />~~ <br />~~ <br /> <br />C ~, <br />~ ~ ~, ' <br />r ~ ~ <br /> r*7 <br />•~' <br />~~ ~ <br />A ~ 1 <br /> r*7 F"- ZT 37 <br /> <br /> ~ <br /> r-~ ~ ~ m <br /> <br /> (_w,7 V `~ Qr~ <br /> <br /> <br />2 0 0 9 0 4 ~s 4 ~,.~,~~ ,~~ ~~~T 31o~s:~ <br />CERT[FICA7"E OF DEATH <br /> t. DECEDENT • NAME FIRST MIDDLE lA$T 2 SEX 3. DATE Of DEATH rAtdrlrl Dar. Yead <br /> Pauline Waters Female November 26 2003 <br /> .. Crrr AND STATE DF BIRTH rr ben U.S.A. rwrr eauayl Sa, AGE • ladl B.vlaey UNpEp t YEAR UNDER r DAY 6. DATE OF 61RTH rAapi* oay. Yar/ <br /> Vernon Iowa rR.l ~$ ~r MO5 aArs ~. HouRS Mws Ma.. 26 192$ <br /> T SOCIAL SECURTIr NUMBER 9a. PLAGE OF DEATH <br />~~ ®~• OTHER ^ Nurarrtlrbme <br /> 4$3-28-4943 ~ <br /> <br /> FACILITY •NaIT1a /Nno1 •Mellran 0^'+M'••laro nurbad <br />lb ^ ER ~ ^ 1~••'d•^d• <br /> . <br />Nebraska Medical ~ Center iversi ^ D0A ^ °rir `~"""' <br /> ee. nrr rows OR LOCATX7N aF DEATH 9d. u+slDe Crtr LBrITS a. CouNTr OF DEATH <br /> ~~ ra ®No ^ Dougla$ <br /> tk RESIDENCE -STATE 9b. COUNTY 9c. Cm. TOWN OR LOCATON 96 STREET AND NUMBER /hCNrdrgZp Carol 9r. INSIDE CRY L9dlT3 <br /> Nebraska Hall Grand Island 109 State St. 68803 Y~ ®«~ ^ <br /> - I•.Y.. WIS. Black. Amman Y1dan. t t. ANCESTRr Ia.g.. IOeian. Meiwen. Gamlan. MCI 12. ®MARitED ^ WM)OWED 13 NAME OF SPOUSE rr .+b. qna miaWr nrnrl <br />A <br />10. R <br />C <br />E <br />- <br /> --- - ~ ~---- <br />.. W1LJ~t~ ..- ..... _ .- <br />~ <br />j <br />~ <br />~ <br />NEVER oNORCED BOb Waters <br /> 14 u$UALOCCUPA71pN rGrwkMAd+a~rArMdnpman taD. XINDOFBUSWESSWWS'~"RY t5. EDUCATION ISpeddyaM OI•darA^rd•1+df <br /> d aOr.atp d11R Nrn ~raFaAl EMmlanury p Sar"Idarv 10.12) CMMge 11 a a S• r <br /> Mana er es a <br /> 1Q FATHEp -NAME Fp5T MIDDLE LAB7 17 MOTHER flRST MIDDLE MAN]EN SlIR11AME <br /> Rex Hems. er Neta <br />~ tB wA$ DECEASED EVER di u.3. ARMED FORCE87 t9a. 1ortOtMAANT-NAME <br /> (YMF. na nr rr11c ~ IM y.ry. aYe wane aalu d senbeal <br /> Na Bob W~~ters <br /> 19b. INFORMANT MAaJNG ADDRESS ISTREET OR RF D NO.. CT(Y OR TOWN, STATE. 21PI <br /> 2109 State Street Grand Isl~~nd NE 68$0 <br /> 20.E • SIGNATURE a LIGEN5E NO. 2ta MET/gDOF OISPOSIf10. 21b. DATE 2tc. CEMETERY OR CREMATORY NAME <br /> ^ BMW ^ RarrorM T1ec. 1 2003 Central". NE Cremato Serv <br /> . FUNERAL HOME -NAME 21d. CEMETERY OR CREMATORY LDCATgN CITr OR TOWN ATE <br /> f el Funeral Home ® ^ °°""°" Gibbon NE <br /> 22b. FUNERAL HpYIE ADDRESS ISTREET OR RF.O. MD.. C(TY OR YDYYN, STATE. ZIPI <br /> 411 West 11th Street P.O. Box 126 Woad River NE 68883 <br /> 23. MAAAEpATE CAUSE IEHT'ER ONLY ONE CAUSE PER LY7E FOR ra1.0A. AND Iql I~ <br />y/^'+I ~~J~^~~ ~ a•~' <br />PART <br />~ I <br />~ <br /> , <br />IrK ~ JI <br />L <br />1~ N 7 i <br />57 <br />' <br />i~ <br />~ ~ <br /> I.I <br />- <br />[. <br /> DUE TQ DR AB A CONSEQUENCE OF ~ Mwrval hNwren oneM and deem <br />I <br /> I <br />~ •. ~ <br /> MF'Yil batwM1101Ye1 and deam <br />DUE TO.OR AS A DF'. <br />1 <br /> I <br />lel I <br /> OTHER SIGNIFICANT CONpTM~NS • CandNww calWAaltllq b ab deMh 4u In1 ralalad PART 111 IF FEMALE WAS THERE A AUTOPSY 25- WAS CASE REFERRED TO MEDICAL <br /> PART l .' }may ~ /B. PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER <br />a ~ ~ ~ 1 ~ ~~ <br />~ <br />~ <br />~L <br /> /yllKL 10.5.1 rMt Nd Yp ND Y1p{ Nd <br />{M <br />~/.~ <br />l~( <br /> 29a ~ 2ab, DATE aF IlLAIiIY (Ab.. Ary. YrJ 2Bc. HOUR OF nuuRV 2dd- DESCRIBE HpW ?L11/RY OCCUFpED <br /> ^ ACCAyMe ^ VIK1NMmI1rd M <br /> Sucde ~ Panaltg 2Ea. tN,ApW AT WORK 291. ~r ~ r ~N .IYm. rier~- 4Cby 28¢ LOCATION STREET OR RF.D. Np. CITr OR TOWN STATE <br /> ^ Hdmlcida MeaugMWl Yaf ^ Np ^ <br /> 27a. DATE OF DEATH Ab.. D•Y. Yrl 2Ca. DATE SIGNED (Ab. Dar. Yr l 2BD TIME OF DEATH <br /> <br />~ November 2~ 2003 M <br /> 27D. DATE SIGNED IAay.. Day. Yrl 2YC Td.E OF DEATH ~ ~ mC. PRONgJNCEp DEAD /Mb. Dry; Yrl 29d. PRONOUNCED DEAD /hburi <br /> ~ ~ <br />Dec. 2 2003 <br />3:35 A M y <br />s6 <br />s"~ <br />M <br /> s 27tl. To IM 6aM d my . dM1eI aarvred M tha ama, dMe snd dlaca and dlla b M ~ ~, 2M. On rr eria a1 tnuunlnawn am ar +wNgtwll n my spawn deam awarad M <br /> CalMlil MaMd <br />~ $ a M 6rIM. rob and P~• and dua b er ealwelel MaMd. <br /> Mb Tine <br />and 7Ma <br /> 2B 01D T OBACCO USE CONT TQ THE DEATM 70a HAS OR E O <br />~ GWITgN BE EN SIOERED'I 30.6 WAS CONSENT dRANTED+ <br />^ <br />~ ^ <br /> ^ UNKNOWN ^ rE <br />^ rES <br />~ I 5 Np <br />YES <br />NO <br /> 'Pr1,~31CMN OR COUNTY ATTORNEYI IT1p1 a Phab <br />31 AHD ADDRESS OF CE IPN <br /> <br /> 7Ba REGISTRAR ~~~.• <br />'~ ~° <br />~ 32b. DATE FILED BY REGI RAR /Alx~Dry. Yr.J . <br />UEC ~ ~oa~ <br /> ~ <br />is <br />~„# d~~t~1~ th ~a9tlik to°~~ a tr~.N c44Y e[ an original record on Eile with vital <br />Stmt des', A(~ougl ~nCx:#~eaL~th Dapart~~ent• ~~• Nebraska. Certiiled cvpiee gust have <br />a~`rsi ~seai~n the ea` ~l~C?~ lett. kLproductions of this green certificate are nee <br />legal pies. ~ ~~~~~roo3 ~~ ..r' <br />~~~t,;;, a4 w'r 1legiserar~ <br />~~~ ~ ~ <br />