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<br /> Lots 8 and 9, Block 66, Wheeler and Bennett's Second Addition to the City of
<br /> Grand Island, Hall County, Nebraska.
<br />
<br /> 2 0 0 9 0 8 0 3 8 STATE OF NEBRASKA 97S~ u
<br />
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND
<br /> HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON
<br /> FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES,, VITAL wtCoRpS
<br /> OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br /> DATE OF ISSUANCE .
<br /> STAL PER.
<br /> SE Q 1 2009 2 0 0 9 0 7 9 6 2 A
<br /> SSISTANT STATE REGISTRAR
<br /> DEPARTMENT OF HEALTH AND
<br /> LINCOLN, NEBRASKA HUMAN SERVICES
<br /> STATEOF }SRAM DWARTAMTOFMBarA Ate AN MVXU MAWM AM go"MT
<br /> Y17ai1. 91'A,7TAT1G7t I
<br /> CBRMICATB OF DEATH 8 07254
<br /> TDEZ EFamf - NAME - FIRST MIDDLE - - LAST -T2. SEX I OATF OF T,--A , 1 1*, Merl
<br /> Levi John Jackson .lame 11,19"
<br /> 4OJTr ANDSTATEOF TN 1FM9RUSA.IMIA.,&oo0 IM. Aw. LMI :DNpER1 YEAR IDA OF IgtTN ,Iia1/i Oay y„M
<br /> eeler Cnmm, Nebraska 89 M~ PAYS tfsk,
<br /> Wb d
<br /> A
<br />
<br /> 'URFIYNIMMIEN
<br /> 58 -24-098 rloSrrrlu ❑ IN1elIrY DTNER El NlAyug HP
<br /> m FA(,yITY • Narro wAwnwroAPwawwarATrwld.rl ER OugMM ❑ R,eNpA`a
<br /> St. Francis Medical Cater ❑ oaA ❑ alp l*
<br /> pc vTY TOWNORLOCATKINVF TN sy. Ni$IpErrrY UMfI•$ M. COUNTY OF DEATH
<br /> Grand island YK ®N. ❑ Hall _
<br /> i 9. aESADOC.E • STATE gg COUNTY 9[. CITY. TdNN ON L mm IQ STREET AND MJMBER /freA,dr AD C"I 9e rNSIDE CtrY LMT{
<br /> 4 Nebraska Hall Grand Island 818 East 13th Street, 69801 I ®N. ❑
<br /> 1D AACt - la¢j. WIW. B!.c An voW 11 -ANCESTRY I.% *0611.lMwp4 Q.f1nYL 11k1 12 ®MARRIED F-1
<br /> wmoilIED 13 NuE OF SPOUSE rff +wmv*-, ~ '
<br /> 1asc~[ Americas "R OIYORCED Murldine Camper
<br /> 1w - DCG`WATK]N
<br /> & av lurkPfewvS ~+F AaY~maM - YW RINDOFMINEWINOU5TRY EDU~iATom
<br /> Shut Cobb I`/?C?/'o!W n'41,NM P.O. Fa1pM~
<br /> Ao~.gAMPbler Cobbler 11Yn7Y Shoe Industry Q ENmnLMNyoSwrl.;Jrv10121 C1q*eS4.S-I
<br /> V
<br /> +9. RATHER • NAME FMI .NDp.E LAST tY MOTHER FIRST MIDDLE MAIDEN SURNAME T
<br /> Bea atmin Jackson Ida
<br />
<br /> le was DECEASE) EVER w U.S. ARMED 1.1111 t f 61 OF A AT . NAME Furs
<br /> (Yes .a. n any ~ IK Vw. gm wr ens dweF d.w.o.u
<br /> No -Murld
<br /> 1011 NJFORMANN AU1p.M1D ADDFESS fSTFWFT OR A F D NO, CITY OA TOWN, STATE D%
<br /> 518 East 13th Street, Grand Island, Nebraska 68801
<br /> ."h
<br /> NO 2
<br /> 1a ,ETIIDD OF pI$POg1TgN 1271, DATE 21c. CEMETERY OR CREMATORY NAME
<br /> S'GN/ITU OL
<br /> 7
<br /> #1071 ® 9" ❑ R. w 06/16/1998 Westlawn Memorial Park Cemetery
<br /> 1 UNF.RAL HOME • NA E 21B CEMETERY OR CREMATORY LOCATION CITY OR TOWN 57ATT
<br /> Apfel-Butler-Geddes Funeral Home ❑0 Grand Island, Nebraska
<br /> j 2211 FUNERALNOMEAODRESS ~•-.STfCET pR R.F.D NO•CrrV OR TMVN STATE DPI -
<br /> 1I1 1123 West Second Grand Island, Nebraska, 68801-5899
<br /> .2 rPAR.1 MIaEDuTE C AUSE (ENTER ONLY ONE CAUSE PEA U ICU UE TOCONUE TO. OR AS A CON5EOUENCE OF - enervw nx..erl anal one AeOk
<br /> Ic}
<br /> PART OTHER SMNfICANI CONDITIONS • GgrYla My tWI[y.ng p iM gHPI but m ftimW PART AI W FEMALE WAS THERE A 24 AUTOP5Y 25 WA's CA$F REFERRED TG MEDICAL
<br /> a PREGNANCY M THE PAST' ~3' 7MONTHS, i MINER OR WWAILA
<br /> IAge% 10 b41 Yea u Ng 1 Yes No ~Vee NP
<br /> 2dc !6E h DATOF PFXIRY (w ow Y.1 25C HOUROF PMRr -yP, Oes RISE HOW INJURY OI,-H ED
<br /> f w;~Perx LJ UnaPle•rmrgg
<br /> I _ M
<br /> I Sxrb Per,ewy 12.9 Ki1L'RY AT WORK gel PL,.C qVJ Y,` t~,Wm-1 I-v ZRg LOCATION $TRF.ET OR RF.P NO - [.ITY qR T('1YN ;'TAT(
<br /> w.rnrcmF - - nyrest,ganon I ~Ya ❑ No ❑ dFte uuung
<br /> v i 2T, DAT[ OF DEATH ;A(>LNy. YIf 2pe C,''fE MINED jw Dav Y.1 i 7Ery TWE OF DEaYH
<br /> , 21 7b DATE SIGNED /Mo Gar. Yrr 27e TIME OF DEATH UN E D 1 wy r/ 2BO. PaO+:~;ILv>;~?i AD -.x'}.^TMT
<br /> In etw4:7=1 Tkrowbege eawA ceeuned w tele deee *W do b we dW 1
<br /> end T4.....
<br /> 29 (>tD TOBACCO USE TRIBUTE TO HE DEATH? ~ 90. HAS OR TISSUE IA]NAIgN BEEN CON$IDEAEp' 30b t$ $ENTG TFD° II~~II
<br /> ❑ YES ❑ 110 UNKNOWN I^--I YES N1; 1 " YEE IV) NC
<br /> 31 NAME ANDiODRESSOF CERTIFIER IPHY$ICIAN,CORDNEHS PNYSICIANORCOLWTYATTORNEY! ItIP "I"--------^--- "'r•'"~PPPPf111,,,-__~~-•T
<br /> ~PP-EeMN/ f•~ T,., 7 ~q~+ `(~p/',7
<br /> V1 -1 -
<br /> 320 . 151 rar A3I~rzp', - A[,0, d. _111 1,R_LLd..--4aF(• .-....-CSC)_l O 1
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<br /> mm 'JUL 1
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