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<br />STATE OE NEBRASKA-DEPARTMENT OF HEALTH
<br />~~~ ' + j-~ ~ ~2 ~ BUREkU Oe YITAL STATISTICS 7 ~ 1 ~ % ~ 4
<br />V l CERTIFICATE OF DEATH ' _ ,
<br />DECEDENT-NAME FIRST MIDDLE tA57 - ' SE% ~ DATE OF DEATH !Mo , Ooy. Yr l
<br />Flo d E i male ~ Se tember 2, 1978
<br />ssterbroak Bossen ,? ~, P _
<br />RACE-(e. g., tv ., Blaci. A..nrrton!ORIGIN)DESCENT(, g., t!ailnn, Me::can, :AGE-tn.. 9.nnnoy UNDER t rFgx UNDER , DAY pgTE OF B«iH (tip . Doy, Y.
<br />Indrnn. eK.l($Rt<I•/,! iGerraan. sK )(Specify/ :(Trr.) AIO$ DAYS: MOVRS. MIN$•'
<br />.whine ~$Danish-American Ian. 71 !ab. I~ , Aug• 28, 1907
<br />CITY ANC Stai=. Of 61RTN (fE nor .n U $ A., -;CITIZEN Of WHAT COV TRYN~MARRIED, NEYER MARRIED, ~ NAME Of SPOUSE (If .,f°, g,.a .:o:den .e•n.)
<br />na ~arr,; ~ WIDOWED. DIVORCED fSaec~lyl I
<br />R Arcadia, Nebraska !P U° S. A. ,)D married I,, Pauline Sorensen
<br />$OCIAi SELURitt NUMBFi 'USUAL OCCUPATION(G~ae Y~nd el.~o.t done da.:ng .nolr ~~%IND OF BV $INES$OR INDUSTRY .COUNTY OF DEATH
<br />'ot ~ork,ng l,fe, e.endret,red) '~ r:j~l v; ~%al le
<br />iz50fi-30-2977 !I,~ureau o£ Reclamation .u), Government i,.a Y __
<br />CITY. tpwN OR IC>(AT!ON OF DEATH i INSIDE CITY LIMITS 1 HOSPITAL OR OTHER INSTITUTION- Nome tlF nol :n e~lAe.. t NOSa Oa :NSt I. °•° DOA
<br />~!$P+<ilT Yet Pr No j g,re er d umber/ f O..Pe~:°..,Fner to OI°°°r~..~ (See. rr
<br />,,, Ord ~,k yes Ii.d-~~a11~County Hos~ital!I±~ inpatient
<br />[ESIGENCf-STATE :COUNY ~CItt,TOWN ORfOCATiON (STREET AND NUMBER ',INSI~ '.ITY {IMIT$
<br />,>j~lebraska ,SbHall ,x Grand Island iud4612 Tara Place ,$t yes
<br />FArHFR-NAME FIRST MIDOIE 1A51 /-OTHER-MAIDEN NAME FIR51 M;DCIE lair
<br />is Christian Bossen ,,, Edith Easter_brook
<br />WA$ DECEASED EVER IN V 5 ARMED fORC ESi : rNfURMANT-NOME--REtA iIONSHIP--MAILING AQD~Fjs« 'SitEft Ot ~f p rv0. C1TT Ot TOTS N. SigiE Z1P)
<br />'•. -,~ ~••,~__'.•~'•,•••. •. 4016 Tara ClaCe
<br />,a no ~ ')RPauline Bassen-wife c;rand_Isl and. LvE_-68Rfli
<br />gl'RIAi, Cren.P*ro.. Remawl'DATF !CfMETERY OR C[EMatORT--N.wE -IOLAitph CITY OR TOWN STATE
<br />zoa.Burial ;zob 9/5, 78 1Dc Arcadia Cemet_e_rv _ i:Od _Ar_cadi_a. N2hra~ka
<br />EMgEk [R-St-NA7VRE 1 iT,IC O / A ) ; ~...PUNFRAE HOME -NAME AND ACG[E$$ ;STtftr OE t f D NO-. CI{T De (Own. STaif. ZIP(
<br />z .y ~,{~~-~~{~-,-,~.., Ord P9emoriai Chanel PeOe Box 230 Ord, NE68862
<br />i To we ° ~ ef:a as M .w. o. m. ea... °I . ea.°. ,,. ..,R°«e~ ,.. .°. e.a.k M..r.w a,
<br />a : ma.ef~ .a+wy ^~ ~ °'~ - X20 .we .... a-~•. °.e v'«. end d.,. ro • s .o.WJ.vM °a
<br />_ ~Ik :S.g h...°aa °~~~~gt ~~,'a. ly1.D ~ ~2.n rS.R„o.... a.d i.n.:~ ..,
<br />~: ~DaTfS FD.MOn yY.S~'F~~`-,-Ja~`DEa1x~ T.L~.__ ~a IGNFD (MO. DPy. Y.) :M UR fDFAN
<br />:a,nb;, t i ~~ tom' ~ :az - 10115 P. _ "-_i°'z.s ~is[ M
<br />c "DaT~ aTn( ,.T '~~ -j0 :PRONOUNCED DEAD ;PRONOUNCEC DEAD (Hoar)
<br />' = V _ :IMO -Day. T. ~ ,
<br />` z~ Se~te:ni~er 1973 ,,_
<br />re.gM[ ANJ wJJtF» Ue ittl:r:fa ;eHT>1iiAN IUYUNf a"} !HT]IL IAN Ja CU'vNlr •1IU[N[TI llrpe Or Pr•nr)
<br />zs Dra lkame L Zlomke 400 South ?yid O~_d N raska 68862
<br />Rf:al'$TRaR _~ ~j ~/}/{~y'~/~ ~ ~ f/ DATE RECEIVED BY REG~I{/SjTRAR f(Qf, r I
<br />_ :ae ~st.a'.,..~ WY r~~~_ //y% a~ [~"L/"iI" '166 L ~ ~` _ ~v r.
<br />~ 2T 4A.tfDUTE CAUSE iFNTER ONET ONE CaUSF tER VNE FOR (a;. Ib;, wND ([li n:...°I ee....• e.... oed deem
<br />raRr
<br />',~ Cerebral Hypoxia , i~crefrsind_over few nt'.-ts Severe 24 hrs
<br />DUE TO. OR AS A CONSEOVENCf OF - . ...ot b...ee.• ..a.. o-a a.°+
<br />..: Chronic ohstructive_~uimonar~ disease ~.~ _~?~-30 years
<br />DUf TO, Ot !fs A CONSEOl;ENCE Cie _ ... .-.... a°>.°.. °ew e+a awn.
<br />Chronic cipparette smokin - ~ .(~~ ~.r~p$~'G _
<br />PA[T O[wfa SK TCwNi LDNb!F+OI+S-LMd+.w .°.ee. . G..n. e~r s ~..e'sui .r n tE.uat S rNttF w wu*O[Sr ...} C ~SE S FtaEEY'LT'dFbTC IS-~---
<br />R eRFG.taNCn !H tnF eASr T y,w Twin :Spe.:ry r.. °. Na. ftwNN W COaCNkt
<br />Arteriosclerotic cardiovascular ~isTe• ~__.` '.E no_ `'"``'""'"'
<br />_- - 7P __ _.-._
<br />ACLIRt+~ SUKPJ[ uOMtC~. ~wp,T. pair a Artier .M. 2aa .. r-.:.e Or -w._e MXnaF ~+. IN: Wr OCC_uEL
<br />O abWee,^, e+vESYi,M.T91:.Sr«+r-
<br />3C ]De JU[
<br />____. -_-_-___._-. ~. ____.-- M XM-~~__ _,__~-_...~__.-_~_._~_.-
<br />eN,•;gr at 'a'Df rta<E Ot 'w ..r. .nr rw. ;rCa. ~r S•af E1 O! a f J we .Inn M TOr+N Srwr!
<br />. -aarh Y... w.. .HKe w.,e.., .. ...e-
<br />_ 1S. i]Of 17..
<br />WHRt,': Y'SIS COPY C-iRRiES T?3E Rr`.ZSEP $EAL OF TH£ !vEBRASP.A
<br />" STAfiE R£.P-ART:~:E?:T CF HEALTH, IT CERTZr'Z£S THE ABflL'E TO BE
<br />d TRUE C€3PY C !fir flRIGI?iAL RECORD flN FIL£ t+'ITH TH£ STAT£
<br />_ ° Z)EPARS~~fiT OF HEALTH, BCR£A`u' OF VITAL STATISTICS, WHICH
<br />i$ 2$£,`i,ET..;L DEPOSIT^vRY FOR '.'Zfi1iL R£CflR~S.
<br />~ .'. Fr E
<br />Y• !BIILECTOR OF iTITAL STATISTICS :'~I~PSSZ~_ ~_ ~ STATSISTR.~.Fa
<br />- LINCOLN, A'EBR4.SYA =5sued June 1, 1979
<br />Lot T!:irty Five ('S),ir, Ra:~enw'ooEj .ubdiYFisian, located in t;~~e nLlt!; -x.>_r` ,~~
<br />the So>~theast :3~Farter (S~S£'_J o: Sectsan 2?, To.,*nsiTin 11 too-th, i,ange o .
<br />Wept of the 6th P.*;., mail Cour.tp, '.re~arrtska.
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