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<br /> STATE OF NEBRASKA-DEPARTMENT OF HEALTH
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<br />J+C7 BUREAU OF NlTAL STitTlSTICS
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<br />ICATE OF CIEATO~i _ . ~ ~
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<br /> CITY AND TATS 6F BIRTH. 11f nol in U~S.A., CIi1ZEN Of WHAT COUNTRY MARRIED, NEVEq MARRIED, NAME Of S
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<br />-~ WAS DECEASED EVER IN U.S. ARMED fORCF3T INFORMANT-NAME-REUTIONSHIP-MAILING ADDRESS ISTRFET M R.r. D. NO.. Cm OF TOWN. $TAtF. IrN
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<br />BURIA4 Cremation, RPmmal DATE CEMETERY W CREMAT~SY-NAME LOCATION CI~T' TOWN STATE
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<br />kHE~i',~ItiIS"COB.'2 CARRIES THE RAISED SEAL OF TBE NEBRASKA
<br />~,£ tl~ AR'TIt T OF,' HEALTH, IT CERTIFIES THE ABOVE TO BE
<br />',1~''T UE SPX.:. n e~N,kURIGINAL RECORD ON FILE WITH THE STATE
<br />r lD~LT~4~~" ~ I~I;TH. BUREAU OF VITAL STATISTICS, WHICH
<br />T'S}~T~E''L~t~~'OSITORY FOIt VITAL RECORDS.
<br />DIRECTOR''t?P'V~TAL STATISTICS AND ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA Issued September 4, T979
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<br />SOCIAL 3ECURITYN MBEt USUAI OCCUPATION iGiw Find of eerF Bono during mad KINDOf BUSINESS OR INDUSTRY COUNTY Of DEATH
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<br />CITY, TOWN OR IOCATION OF uEATN INiI ECITT [M[ITS NOSPITAI OR OTHER INSTITUTION-Name (1l nal in eil Far, Ir ND51. OR w3t.IMkeN DOA.
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<br />RESIOLNCE-STATE COUNTY TTY, TOWN 00.lOCAT10N STREET AND NUMDER INSIDE C(IY UfA1T3
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