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<br /> RE: Lot 23, Block 3, Lake Davis Acres Subdivision, Hall County, Nebraska
<br /> STATE OF NEBRASKA
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH A'ND,
<br /> HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL kECORD bN
<br /> FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES; VITAV'PFCUkDS
<br /> OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br /> DATE OF ISSUANCE
<br /> STAND COOPER
<br /> ,AUG 1 2 2009 A~'S'F5 NT.4Tflr'E-R~GPST, AR
<br /> 0 3 6EFIAR", F. T oF~E,41-*>~ND
<br /> LINCOLN, NEBRASKA 2009790
<br /> kuU ,A -S RVI E
<br /> 4 x
<br /> STATE OF NEMASKA_oEPAI wwT OF NEALTM 0 91.518.
<br /> BUREAU Of VITAL STATISTICS
<br /> CERTIFICATE OF DEATH
<br /> . -NAME FI MibK1 . LA X A .[Ma.. pay. YrJ
<br /> Peter
<br /> f)ENAR'r') Q's0N 11.
<br /> RAC -(e.B., While, Block, ANMr► en ORIGIN/D S[ENT(e.y., halien, MMnkrn, AGE-loo Valid" UNDER 1 AR UNDE 1 DAY DATE OF BIRTH (Me,; Day, yr.)
<br /> Indian, ek,)(SpeciFy) Garment, wk.)(SpeciFir) (Yn.J MOS. DAYS HOURS. MINE.
<br /> American 6e. 6c. OS-
<br /> C AN TA E OF BIRTH ( Her in U.S.A., CITIZEN OF WHAT COUNTRY MARRIED, NEVER MARRIED, NAME OF SPOUSE (N wife. B' er9i n Horne)
<br /> name country) WIDOWIFD 'CED.(Sp9cETy) y--~ Bauer .
<br /> B. ea a Co Nebraska Ti. S 10. 111. ~l `T
<br /> SOCIAL SECURITY NUMNER USUAL OCCUPATION (Give kind of wrk done during Mw!l~ R) .OF BUSINESS OR INDUSTRY COUNTY OF pEATH
<br /> I*f'earlinplint", ifrefired)
<br /> 12. 508-40-0657 17r. - 196 I4a. JD p -
<br /> CITY, TOWN OR LOCATION OF DEATH INSIDE CITY LIMITS HOSPITAL OR OTHER INSTI UTION Nolan (if na1 in eirMr, "I Rr. W T. I.dkrh OOA 'i
<br /> C1.1r.1ian1/E . In., . Item (1111-0 )
<br /> /f//7 I - (Sped Yp or Ns) piw heN and nesber
<br /> )4b. y Gr. 1A. MAC. led. 140.
<br /> RESIDENCE-STATE COUNTY C TO OR LOCH ION STREET AND NUMBER INSIDE CITY LIMITS
<br /> 1So. /'j 13 b. 1Sc. (p (Specify rips of No)
<br /> L =zL 1 S:. C
<br /> A FEII•-NAM FIRST
<br /> MIDDLE LAST MOTH -MAIDEN NAM FIR MIDDLE 5
<br /> Henry V. Nelson Christine Raun 17. WAS DECEASED EVER IN U.S. ARMED FORCEST INFORMANT-NAME-RELATIONSHIP-MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR 101Oe ".1,P) Ne....
<br /> ~s. ~NoOli l(11 ye., R,.. .ra. ved danF Of
<br /> »mr.) ,,,.Mrs a Judith Nelson-Wife, 4622 Calvin Dr., Grand Island,
<br /> lob BURIAL, Cremation.Remo"ol A CEMETERY OR CREMATORY-NAME LOCATION CITY ON TOWN STATE
<br /> 2Dr. Burial 206. 9-2-78 20c. Minden Cemetery Mind_e_n, Nebraska
<br /> IMI A ER-- NAZZL4~,21q& cENENFUME A~EBuNAME AND ADDRESS tler Geddes F(STREET br.
<br /> M1'68801
<br /> Funeral Home ~12~ We 2nd
<br /> 21. g ,
<br /> T9 bed of my ine.ledee, des16 line. date end .d drw » N.r On Ibe brut at r.e*M.eNen rd/er b,..q{Brliva. Mn rpleire dralb .uurmd at
<br />
<br /> cee.N.I "Wed, lZ C,. At. riete. dNe and PI_. .it dw N Mr .-tal .
<br /> y(X 22a./fiBaehrn and To.) ■ UZ44,w-, too ' 101 210.(SiRnefrn 6-41 title) 111.
<br /> ~rLiii^^ DA 1 2(Mo.-,-boy, Yr.1 HOUR Ofyy ?FAT" 101 ATE SIGNED N6. ay, r.
<br /> 23b. l 123,. !G~ MAX,
<br /> 516. 21c- M
<br /> 3 PATE DEAT Me., a. Yr.) I la PRONOUNCED DEAD PRONOUNCED DEAD (Hour)
<br /> 7 S (Ma., Day, Yr.)
<br /> 22d. / • u M .
<br /> RAM AF 40 RTIFIER (PHYSICIAN, C EC PHY IA OR C LINTY ATTORN Y) (Type er PrinM)
<br /> 2.5. j'0'V 14-1 49 A) 40 .4,,aj- Av UAW
<br /> E RAN AT R CEIVpD Y WEGIS.11 Day, Yr.,
<br /> '
<br /> 2Aa.(SwMIMr.)R :r
<br /> CER-IM8
<br /> 7. IMMEDIATE AUSE (NT 1Y ONE CAUSE ►ER LINE FOR (e), (6), AND (c)) , Inlererl brh.rw, -wo end d.916 '
<br /> PIT
<br /> a) CA 96 A
<br /> i4t-
<br /> DUE 10. R A CONSEQUENCE Of- , Inren,wl ►rl.rrn .,net ed dead,
<br /> (W OA Nl GT- W 0 Q
<br /> DU oR A CONSEQUENCE OF1
<br /> (NI U 1 1 ' U' nIl • L)' wa q
<br /> R IGN ICANT OHS-Cwdnlbw. eeaMbNiwR r. d.aN, br/ nN r.laM.d PART III. Ii FEMALE WAS THERE A AUTOISY WAY CASE NEFEIIIIED T NM! AL
<br /> PART PREGNANCY IN THE PAST y MONTNSr (fpee", Yea Or Me) ERAMIHER OR CORONER
<br /> (J•ui r) ILA- .,065 U P Yee C] Na 0 (Specify T W NO)
<br /> 26 . 29.
<br /> ACCIDENT, SUICIDE, HOMICIDE, UNDET-, DATE OF INJURY , Day, Yr-) HOUR OF INJURY DESCRIBE HOW INJURY OCCU _
<br /> 011 PENDING INYtSTIGATION, (Speeity) .
<br /> ]OD. ]Ob. 9/1 -7 7 20c. D 3 CJ M ]Ode : w Nr r C<.
<br /> INJURY A WORE PLACE Of IN)U f 4o. dre9r, 1904", LOCATION STR[FY N.F.D. Nee [IlY OR TOWN. STATF
<br /> (SP.•Ir vs. Or Iva) /Mice 41.11M02. we. (S)N,eor)
<br /> e- (Ve -4
<br /> JiL
<br /> i t' i4, e.
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