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<br />t ~~+.gy STATE OF NEBRASKA-6EPARTMENT OF HEALTl1
<br />]1~~.. ®V+r~V~~ BUREAU OF VITAL 5TATISTICS 7 8 13 4 4 0
<br />CERTIFICATE OF DEATH 1 i t/~^~~'> __
<br />DECEDENT-NAME FIRST MIDDFE 1A3T SEE ATE O DEATH (MO., Doy Yr,l
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<br />RACE-(a.q.. WhiH,Rb<k, Amwr<an ORIGIN/DESCENTfq 9.•iralion. MP.iion, AGE-1ml a~nkenr UNDETIYEA0. UNDERI DAY DATE OF GIRTH (M0., Day, Yr.)
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<br />Ct AND S ATF OF BIRTH (1 rwl in U.S,A., C{TIZEN OF WHAT COUNTRY MARRIED, NEVER MARRIED. NAME Of SPOUSE (tl rdq, qm ma~dwn rwmnl
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<br />SOCiAI S(CURitt NUMBER USUAL OCCUPATION (Girq kind o/rah don. during moH KIND Of BUSINESS OAINDUSTR'( COUNtt OF PEATM
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<br />CTTY, TOWN OA FOCATION Of DEATH INSIDE CITY LUAITS MCSPITAI OR OTHER INSTITUTION -Nom. l/f not in wdher, n NOY OR IlyT. IndxoN DOA.
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<br />RESIDEItC!-STATE COUNTY G 70V:N OR LOCATION STREET ANO NU~}~ER 1 INSIOE CItt IUUiS
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<br />AY - AM Ip ~~ ~ MIDDkF FA MOTkfR-MA NNAMF ftRS~M U~~~~-'
<br />1. fc!cxtnd ~ l/a.CL I'7 4naee Lucas
<br />WAS CEAS(D EVER IN U $. ARMED FORCES. INFORMANT-NAME-RfLA710.^tSH1P-MAILING ADORFSS 1}IRFe/ OR alp kO.OR OR TOWN lTAtl. 21Pf
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<br />'RUMAI, Ggmolion, Rgmorul'n~~-- CEMETERY OR RE TORY-NAME LOCATION Citt OR TOWN STATE
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<br />~ RR-SIGN7)YURf { tICFNSf NO, FUN RA4 HOME -NAME AND ADDR~ ISTRfEI Op RI.D. NO.. CkY DR TOWN. SIAM, tul
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<br />~~~ .DATE OF TN (AM., Y. Yr.i °0 3 PRONOUNCED DEAD PRONOUN
<br />«$ (MO., Day, Yr.1
<br />~ - 1
<br />iT AN E S a C'ERNFiER (MtYSICiAli, C ER'S PHYSKIAN OR C UN ATTORNEY) fFypP or PrinF)
<br />WH~I 'PHIS .LCOFY GARBLES THE RAISED SEAL OF THE NEBRASKA
<br />,~T~IkF il?,Fi~F,NT of HEALTH, IT CERTIFIES THE ABOVE TO BE
<br />~A 1'1tU,is`~',~~f~f~8 AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />" DAR .f HEALTH. BUREAU OF VITAL STATISTICS, WHICH
<br />' IS•,"FHS ~~~~' DEPOSITORY FOR VITAL RECORDS.
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<br />DIRBCRVITAL STATISTICS AND ASSISTANT STATE_ RE6TSTRAR
<br />LTt3COLN, NEBRASKA ~ Iss!red September 11, 1979
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