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<br />WHEN THIS COPY CARRI~E$ THE RAISED SEAL OF THE' NEBRASKA HEALTH AAIQ~QI SERVICES
<br />SYSTEM. IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE OR/GINALiQIf~D.~C71iF~A,,E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAB ~ ~.Y~yCH /S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />sE~ X2000 200906624 - ---LL -- ,~~~R
<br />/~SI~TANT Std ~7~~¢~TI~IR
<br />LINCOLN, NEBRASKA HEALTH ANUJ'/UMAAt:SERVI~£&'SY~FEM
<br />---- -- -
<br />SO(;IAI 5F(;l1HTIV NUMREF7
<br />rlf nUf rn U.S.A.. name rnuntry! 5a A(iF, ~ LaSI ftlrlhday UNDER 1 VFAR U
<br />~1 CITY AND STATE OF ftIHTH ~ (Yry I 5b MCIti DAY'; 'T-H~NDER f DAV 6. UAIt Vr tlIHIH (MOnfn. (7,ay Year/
<br />)I1R$ MINS
<br />Tescott, Kansas 75 November 27, 1924
<br />STATE OF NEBRASKA- DEPARTMEN'C OF HEALTH ANA HUMA7sl"SEICES tt'dJprt~E.
<br />VITAL STATISTICS - " - -
<br />CERTIFICATE OF DEATH `-'~'=_'~`~ f
<br />' )( I.DE N'C NAME. FIRST' MIUULF L/ ST 7 Sk.%- - - fl.
<br />Warren A1£red Stun Male '
<br />513-~24-9579 _ _ _
<br />6b FAf:ILITY-Name ~•-~- Il/nnf msfifUlloll, Siva .slraa(.mrl rrurnfx?r/
<br />fla PI A(:F OF DEATH
<br />
<br />Hf:)SPIIAI ~ InpatreN
<br />^ FR outpatient
<br />^ DOA
<br />Ol'HEH ^ Nursing Home
<br />.. ~ Hesldanr:e
<br />^ Other lSpeodv,
<br />Bc CITV TOWN OR LOCa)ION OF DEATH fld INSIDE CITV LIMITS 9e. COUNTY OF DEATH
<br />Br ay nLGH•Medical Center East
<br />Lincoln Yes ^x "~ ^ Lancaster __
<br />9a RESIDENCE STATE 9b COUNTY ~ 9c (:ITV TOWN OR LOCATION 9d STREET qND NUMBER llnr.Nriing7rp Cndel Je INSIDE CITV LiMI
<br />TS
<br />Nebraska Hall Grand Island 4303 Michig_an_ Ave. 6$80 Yea ® Np ^
<br />O etC(i ~Spe~, Whne Rlark AmP.r,nan Indian I I ANCESTRY Ir; Ilallan~ML•x~Can. Gelman, el<:I ~~~ MARRIEp ^ WIDOWED 13 NAME O -`
<br />I 9 ~ 9 F SPOUSE /// wile glue maiden name/
<br />•tyl pe WI
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<br />White f NEVER DIVORCED
<br />erman/Irish/English L~
<br />M RgIEU
<br />Nina Swank
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<br /> ic Manager
<br />Tra Missouri Pacific Railroad 2
<br />.~. O 16 FATHER ~ NAME FIRST ___ _
<br />MIUULC LART I? MOTHER FIRST ~~~ MIpDL.F. MAIDEN SURNAME
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<br />Wi Tam A re St
<br />irn Lim Mae John
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<br />'6 Nl A., DFCFASFO EVER IN LIS ARMFU FORCC57 14a INFORMAN T NAME
<br /> (>+ ~ V,,. 'u ?r unk.l II yr) y vl. war and Ualu; ul serv ,sl
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<br />d ~ ~ Yes I Nina Stirn
<br />6-23-43 - 3-1--4~WWI
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<br />Ian INFORMANT __ _____
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<br />MAIL ING ADDRESS (:ITV OR TOWN STAT. JIP
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<br />4303 Michi an Ave., Grand Island, Nebraska
<br />68803
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<br />` '0 LMNALMEk S GNA I IJNE 3 LI( ENSE NO.
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<br />~ 21 a ME'f IIOD OF UISPU i'G
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<br />Rural RPm,
<br />~.~ ^ Se t 2 2000
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<br />Grand Tsland it ~emeterY
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<br />I O ~ ~ 1 I l1NERAL HOME ~ NAME 21U [, METEHV UR CRF MAT~_!Ry LO CATION CI(v OH 10WN
<br />STATE
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<br />Livingston-Sondermann F.H. ^ r'remakron ~ urrnnt
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<br />Grand Island Nebraska
<br />~ ~ 22b FUNERAL HOME nUDRE55 ISTgEET OR R.F.p. NO CITV OR TOWN. STATE. ZIPI
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<br />601 N. Webb Rd., Grand Tsland, Nebraska 6$$0.3
<br /> G L.1 23 IMMEDIATC CAUSE ~ IENTCR ONLY ONE CAUSE PEH LINE FOHei 'hl AND (cll
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<br />p ' HAH 1 OTHER SIGNIFICANT CONDITIONS Cpndilinn9 Contributing Ip the tleatn out opt r9latctl T r PAH T Itl IF FEMALE WAS THERE A
<br />pRFc NnNCv IN 111
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<br />S"' 2a AUTOPSY 25 WAS CASE REFpRRF.D TO MFDICAI
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<br />~I _ _ C d? a P ~I. vii al ,n ?fie BSURV AT WoORK 261 P ACE OF INJURY . A( home. la ~~~ ?l?y LO(:A I ION S1 HEEI UR R F D NO CITV OR TOWN
<br />~ ~ ~~rr ~ t ~ 9 cn /sHecrryl
<br />)( '~ ~ 27a TF OF DEATH iAAO Day YI'l -~ 2fla DATE SIGNEU ~Mn D,,v Yr I 296 I IME OF DEATH
<br />WF'•: ~ DQ
<br />27n
<br />~'~' ',~ ~'~ ~ 'DATE SIGNEU IMr Uay Yr I 27c TIME OF DEA H ~ 29r. PRONOUNCFDOEAD rMn Day. Yr.) 29d. PRONOUNCED DEAD /Hnurl
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<br />E ~ ~ ~ , CdUSe151 ,talatl 1 `nwlatl P. d r r i `_ ~nd dire Ir' W ~-+ -' 299 [)n ton bas 5 1 xaminal On and Or nvest gaUOn, In my opm,on tlealn occurred at
<br />I ~ ~ the I me date a d place antl tlue to the causelsl Stated
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<br />P9 u10 TUEiAC[ (] l1SF CON TRIBUTE TUT DEA7 30 a HAS ORGAN OH TISSUE UUNq TION (3~N CON SIDFRF D'r 30 b WAS CONSENT GRANTEU~
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<br />31 NAME, ANC) DDRF S`.+ t7F ('F RTtFIER IHHV$ICIAN, CORONER'S PHVSICIAN.OH CUUNTV ATTURNCV~ iypa ur Prrnf) (ter ' /" Qr
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<br />]2. +EGISI HAR ~ ~~ '32b JAIE FII F.D RV RF~~ AR /Mry/p Day Vr.l
<br />~......._ ..........- ......_-_..-_...__. _._ ..._ _.-.-__._ .. ..... _.... _. S ~-,.~i.-~- .. __
<br />SUPPORT
<br />nATF OF DEAIH rM!>nu Uav. raarl
<br />August 30, 2000
<br />STATE
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