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-> <br />WHEN THIS COPYCARR/ES TIIE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES , <br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILL= Wn4 <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEGif W, <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DP V 1 L ft �l ��i A1EEY_S..COGPF_R <br />ASS /STAN' SMAT99WO S 'iil <br />LINCOLN, NEBRASKA 200501975 HEALTH AND HUMAIfIS _00%0 S TEYr1 <br />3TA1Z0F WAWA, AFL =ill , illlif�MC' + <br />u <br />Fs1ST WOWE Lar <br />z M s AIT <br />Robert Thous Barlow <br />*410 Raesnta ,. <br />reAr • � 10fi— <br />6c Ti(B !_ "v 0 <br />AND STATEOFOTTH ffdw0USA.fi~; Aw_ y) <br />Rahzaska <br />Sa A" -LAN <br />"9 2 <br />LMDYIt rEAR <br />ss MOS DArs <br />SO6 -10 -0851 <br />AL RAM OF DEATH <br />HOINTAAL ❑ ""rr' °+►cc ❑ """'`+o" <br />❑ EAOv0d f erarlor <br />Li `"'"�" "' �--" —`-•` <br />_ -M w AAer.rOlAbafA+a9.ra . rNaN9fwd <br />344 East Hall Street <br />C crfY mwoR LOCATDN OF DEATH f0 01ft)E CRY UMITS <br />de COWTr OF MTN <br />Grand Island - Fil - ❑ <br />Hall <br />9 RESIDENCE -STATE <br />Nebraska <br />f COUHRY ft C".TOIMIORLOCATXM <br />Hall Grand Island <br />Ord STREET MD NUIANER ft �;edms� <br />1344 East Rail. "l +�. *► <br />IL W4E-ft&V*ft%wk A91w+ewl Mldfn <br />11. A16ESTNY M9 -OdORt YasblOwnwaxi <br />12. ®YMtED Cl <br />10 AM:E0a1CM .00ftew �MMI <br />ft) White <br />""Imerican <br />oAaRCEO <br />Jos pR ns Svs <br />W IISUAI OCpfN171DN Ki+wANFd9M aaN►AeignwM <br />aR aufr <br />Electr�aian <br />t! NaR00F SU91E35 AYOUSTW <br />Electical Company <br />t5 mummM <br />i Rr <br />oavAm o K -128 8yyf bsMS + <br />a`" <br />Jesse Scott Barlow F Beatrice �BEOVALS Nauss <br />NL WAS DECEASED EVER N us AR►E9 FOROW 199. NNKXV ANT -NAME �. <br />N Dr. Richard <br />No )+�.Aww«) I ■r••v�•PwaAOfweoterYOy Barlon �� <br />N _ <br />If. aiOR1Mw MNTAGADORESS W%ffT OR RFD NO. CRY OR TOWN STATE Z04 <br />3103 11th Ave, Kearney, Nebraska 68845 -333.2 <br />HD. R96AUMR- $10PATURE I Licew NO. 2% METHOD OF DWO9T0N 210 DATE 2k oRLMtAMntoRV NAAE <br />Not Embalmed ❑— ❑,,,,,,o,,, Jmay29, 2002 ldtlmeMHariatrm*c mmbw <br />Ra FUNERAL HOME -NAME 2+d CEIE"WORCREMAT- CWYLOCATON (TTYOPTOWN sum <br />All Faiths Funeral Home ®C G. 1:1DDIQW Grand Island, Nebraska <br />M TYRE W HOE ADDRESS ISTRkT OR RFD, ND. CRY OR TOYM STATE 2H% <br />2929 South Locust St., Grand Island Nebraska 68801 <br />s "IEDW E CAUSE (ENTER ONLY OW CAUSE PER LIE FOR­ ft NO Rc9 eTwa 11t91wesaAfw re wrw <br />PART <br />DUE TO. OR AS A ^,,,++4KEOLfTACE CF <br />0 <br />DUE Tu. OR AS CONISEQUENCE OF i i AM:al wlo�TOWw sAaa/ <br />OTHER S ANRCAW COMMONS - CoTWWW WOMLSl f b M ONO WOW NIw90 PMT OI IF FEMALE WAS TAME A 1 7A AUTOPSY <br />P5 PREGNANCY N THE PAST 3 MDNTwS1 <br />2S. WAS CASE TO �)OrK <br />E7rAar81 ORCDRDNERs <br />IAges,0-.L1 Ye Nn Vs P., <br />yes 1 No <br />709 - <br />21b DATE OF KRM ARP Day. Yc) <br />2& .ATUR OF RAAIDV M DESCRMTE HOW ft_ t OCCURRED <br />❑ AtXQwe ❑ LM,pea"" <br />❑ S&MOS ❑ Pod, <br />M , <br />7f9 fLAXiY AT WOR9 <br />29 an2;rW /AI IIg Awm. Easel. %CWV <br />200. LOCAT*N . STREET OR R D NO CITV OR TO" STATE <br />❑ oewlenye M9M9e0^ <br />Ye ❑ ND ❑ <br />�9'CC''�A1!! <br />.. <br />27a DATE OF DEATH ARP Car 1'.) <br />2f DATE SGSED OW Dow Y: t 2f THE OF DEATH <br />2Y <br />January 28 2002 <br />1A°- <br />N <br />2k PRONOUNCED DEAD ,Lb Qq: yr, - PUONOUSCEO DEAD ,eaRn <br />2R DATE STORED Aide Dry YTI 27t TIME OF DEATH <br />Janus 29 20 2 9 :45 M <br />_ <br />it <br />i Rr <br />270 ToMOeMe1wy1 <br />no 0.wo was dow-w ale Gallo- 09M etc~ aN <br />YAYYlH wwe <br />. � <br />N M,l.9wN aAO9MAOe an0 Wt w 9w Lw1AaIN ie. <br />aM T <br />am <br />129 OlD <br />TOBACCO USE CONTRIM)HE TO DEATW a NAS ORGAN OR TISSUE DONATION SEEN <br />❑ YES ' ❑ ❑ YES <br />� <br />_ <br />7L 0 WA$ CON9BST ORMS16D+ <br />YES <br />V NAME ARID ADDRESS OF CERHiER 0"SKMAL CORDER S PHYSIDM OR COUNTY ATTORNEV, ,T1pOPV.W <br />Gordon J. Hr icek 729 North Custer Av..Grand <br />�o Ur1i! YtllD Nn rESi6_ tw saw -1 <br />FEB 12M <br />