|
STATE OF NEBRASKA-DEPARTMENT OF HEALTH
<br />Bureau of Vi[ot 5tztiatica ~ ~ ~ 4 1 ~ J ~ ry
<br />79"` ~ j(y ~ ~ ~ ~ CEFiTiFiC:ATE OF DEATH U /
<br />DECEASED-NAME nn, r~smae r•a, SEX v DATE Of DEATH `•[ro« w VD.r• reu
<br />I; vn RGF WILLIAM GLASS t MALE jt, JULY 27, 197+ _
<br />ArIaCA« r«DU
<br />e, «
<br />o
<br />C AGE-us[
<br />v
<br />' TeA
<br />D DATE OF BIRTH ~ •ro«rn, JCOUNTY OF DEATH
<br />1
<br />D•t
<br />v
<br />.
<br />E can
<br />RA
<br />etc. +s.eMT t
<br />[ ld~i 1 T E u Iru[s,
<br />s.a 7D rot
<br />wn
<br />,, r ru ,
<br />r
<br />rrou,s
<br />}
<br />ar [ F E e 9 1904
<br />n~
<br />t`
<br />c
<br />a,nn •«D N~ran,
<br />. [„«[
<br />[wor
<br />CTn, TOWN. Ot LOCATION OF QEAtH reCD[ em [wm HOSPITAL OR OTHER MSTf[UTION-NAME ~~
<br />v ,t3 O[ NO
<br />GRAND ISLAND tr YES r, Si ETERANS ADMINISTRATION !-!OSPITAL
<br />n
<br />.
<br />STATE OF RIRM , n «oa i« v . «Ar[ CITIZEN OF vMAT COUNTRY MARRIED, NEVER MARRIED, ~l1RVIVMG SPOUSE ~ n wne, G»e w.iD[« rare ,
<br />t
<br /><wNn. r U . S . A . MnvowED. DrvotcED ~ t.E<n„
<br />NEBRASKA , +u MARRIED 'n. iERNICE ~______
<br />C~
<br />a
<br />SCaCaAy SECURT' NUMBER USUAL OCCUPATION +Wn MND or pro„ Dore DuN«e roar ~r RiND OF 6USINF55 OR i USTRY
<br />Her nseD i
<br />w+.,rra }m
<br />,
<br />:.! SALE 5
<br />. y, $08=D1-0809 },, $ALE$y+AN ,; }a
<br />«
<br />r
<br />[W~n
<br />RESffiFNCE-STAif COUNTY CRY, TOVM, OR IOCATIOra ec Dt cm 5T0.EET AND NVMRER
<br />• ~ r[3 Ot N0•
<br />r~
<br />YES +[. 41'; u. DIVISION ST
<br />w. NEBRASKA iq. BALL }a GRAND ISLAND ua
<br />fATNER-NAME NKr rrop[ w, MOWER-MAIDEN NAME r»n .loon usr
<br />yy~ (DEC) LOUIS GLASS }y{ (DEC 3ERT!1A A. 3ROWN
<br />r
<br />.n, am
<br />t1.WAi OKEASfD EVER iN U.S. ARMED FORCES? fNfORAaANT-NAME-tEUtaONSHiP-HARING ADDRESS ~srun os t.r.D «o , u,v o[ row«, t
<br />tY.a. a waw•..1 f n[ v.A ,i+ r., wd do,ua e[ » crl
<br />r
<br />S F ~l 4' ~ N o8?Gl
<br />i
<br />m
<br />G
<br />w
<br />;
<br />}[.
<br />LAS
<br />tR BERN CE
<br />F;RMY 11-`-+: -o„
<br />~
<br />PART 1 DEATN WAS CAUSED lY. ~ (fHifR ON[Y ONE CAUSE PFR [tNf FOI /aJ. Ipi. AND (<!J
<br />it rrr[Drn Uuf[
<br />/ JAcute n~yocar3iai infaretior. ~ Hours
<br />
<br />:~"NnD..a. ~[ .»..
<br />,<w G.a'E „a ro ,slHypertensi~~e cardiotra.scular disease many ye:xs
<br />?. «"`
<br />i 6 <AVff [
<br />Iq
<br />PART R. OTNEl ,[C•NV[C1J[T COrmnWN3~ COND,TgNS cONnllUfaND M DEAtN Wt MOT ,EIA[FD aA,T Ili 1r i[a{AIE. WAS TNFR[ A AIROPSY ' N TES w .! nrOrNGf COr~
<br />nnGNANCT IN PNE ,Aai l saONiNyv ~ n W D[n ,« Dnttrrnr«G UYH
<br />O[ D Alw
<br />~
<br />a
<br />M CAIa,E GrvEN [N rA,i R.}
<br />t~O
<br />IN
<br />t~v 't'
<br />C1Lt Ct~ty ~f'Oh (ill $'.~ vy hlSt<~ry iEy Ci NOG n.
<br />ACCtOEN, siy+<roE. apMiCaD(. DA ~ ro« . w . .. NOW NOW INIURY OCCUtt ED ~ e.nt, «uvn o• noun n. r.n r o. ru [r rf i
<br />O!-ap~ETERM![ED , ar,Cx+,
<br />tta. tO ]p. M. tY
<br />iNJVRY AT wORi[
<br />1 {RGrr of b r0 r PtACf OF MAMY ., «or. ra,r, s . r.ero[.. tOCAnON ~ men o[ a r o. «o-, c„ o[ w.w. a,An ~
<br />OwK! KDO . [K i yt<rn i
<br />- 74 Ip ~
<br />wrr/w[, •arvF Orr , DrD/ow «Ot vnw ml DEATH OeCUttEO . M rrKl. W nre
<br />w
<br />o+[rw Dna ,a[ A°'o
<br />~
<br />CEREfaGTgN- ..orrv Daa TaM I ..
<br />aOD* •rr[{ oeAm r A.ro ro m [eu
<br />o-atw
<br />wr rtM
<br />na n. fA ~ rnrt <AUaeaOR~E*1b-
<br />'~~+}~^*rD~^ ^" JULY 22 1974 To DULY 25 1974 r wLY 25 1974 D i D t 2:45~ '' °~^'~ePw
<br />n
<br />:
<br />ts< a.uD no.. n{
<br />E D
<br />[ oECea~, .+.s r.orro.re[D Duo
<br />.e.a ~ .
<br />CE4TIiKAT10N-aAEDKU EXAMWFR Ot COtONEt o« ,.[ uses w +ra .ro.. or x•o-
<br />ro.. D..
<br />raw+rw w n[ [oD. uotw a.~ ,..aa,ic.rw. w r. wWro«.
<br />pEAlr O<[ VO[D d ,.[ Nn ArrD Oat b rM 4Dant, n.nD M 7A M
<br />DATE SaGNED rrprra, DA,. ,W i
<br />o[
<br />---
<br />~
<br />`[
<br />I
<br />SrGNAT t I~ ,~J
<br />cettaflER-NAME :,.n oA r...n I t;~ f ~
<br />N. ,)
<br />Itn ,! u lY 25 , 1974
<br />r '~""! [/~
<br />~
<br />.
<br />I n ~~ L- _ - -_ -
<br />.,, a ac
<br />~l4Y'=17 M D
<br />K
<br />D
<br />y
<br />~
<br />D~
<br />ss-C
<br />E
<br />~+~ r.o5P17AL 2201 NORYM ".ROAOWELL. +RAND ISLAND NE o8s01
<br />n
<br />RUIW, CREMAT[ON, REMOVAi CEMETERY OR [pEf[ATCMY-NAME EOUTION <rn a[ n>r. uA
<br />y4 °" BuTisl „{ ~Nr Grand Island Nebraska
<br />DAtt ,rpr,w, w., ,usr fUNERAi NOME-NAME ANO E51 +sr[eea o cn,aro»«. Grand Island
<br />NE 6801
<br />eni
<br />505DW
<br />K
<br />'
<br />
<br />,..duly 29, 19T4 __
<br />,
<br />o
<br />g,
<br />.
<br />s,
<br />:klivin8~ston-Sondermann
<br />€AUAitgSL}S+GE•'AlURf f ,R. C)V ~ •'•~••_-•.••.~_. 7M t:yL /
<br />~~° ~~~~~=k ° 5"-`[.~,..~ ~. f l~ ' ail ~ ~/
<br />'~~'ii&T~_'~EiS COPY CARRIES THE RAISED SEAL OF THE NEBxASKA
<br />STATE'-DEPARTMENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br />;c.y;A.•T~UE-COPY OF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />_ -spgp„ART27,ENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH
<br />=«~ °ISt TSS"v„i.EGAL DEPOSITORY FOR t'ITAL RECORDS.
<br />_•.E A w ~/1 "~
<br />
<br />DIRECTOR OF VITAL STATISTICS AND f,SSZSTANT sTe~>; tcr.~>_~itceac
<br />LINCOLN, NEBRASKA Issued April 2, 1979
<br />i
<br />
<br />
|