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<br />SFATE Q' NEBRASKA-DEPARTMENT OF HEALTH
<br />79-- (~; )~L't"# ~ BUREAU 6E VITAL STATISTICS
<br />7 "L~l! [3a~ CERTI~iCATE QF DEATSi~ ;,.,~ ~~ -
<br />-- --
<br />DE{EDENi -NAMF FIRST MIDDLE UST ~ $E% ~ DATE DF DEATH (MO.. f)oy. Yr.)
<br />~ *tale_ ~ Januar 21 197$ _
<br />, iv1Fti'Iit V,1[iGIt;l Sl_1i+>I.l7T __ 1z 1a.__.- }'._~_z______ _
<br />RACE te.8 WF to 8lack,Amer•con ORSGIN/DESCFNT(e g.,itglian, Menican..4GF turrB nAda~ UNO_ER_i YEARI VNDER IDAY_ DATEOF 5,RTHfMO., Dar. Y..)
<br />Ind+an, et )(Sp ~}Y! IGevman, el:.)($pec~fy/ hral OS ~ -OATS HOUR$ INS ~~
<br />_ <. ;,'E~i to s Bohemi, n ~ea '>----°`----- _ "`,__-~ _ _h.I'eb . I7 I952
<br />` -'--
<br />[ITV AND STATE OF BIRTH (H nos in U.5 • 'CITIIEN OF \VHAT COUNTRY ~MARRiED. NEVER MARRIED, INANE OF SPOUSE (1/+~ie, give maiden nomr)
<br />nan: r.;) ~ (WIDOWED. DIVORCED iSuer~fr)i,
<br />d a~Peu Cloud, Vii; i:.S.:1. _ !,D :<arrieu __ ,, Jane :_:_.__Davenport ___
<br />54CiA(SKURITT NUMBER jUSUAl OCCUPATiONiG<.<k:,,d of sa:k dine du~.g n+osr ,%IN7 DOf 8U5iNf$S OR INDUSTRY iCOUNiY OF DEATH
<br />;aF.a.=,.y rk n•T ren.ed' ~ 'sleaiy r,Yt ui~ent' Bail Count
<br />,z_ SOS-lU-9$72 ~,~ :IeClTanic i`i~',ab _ i,<a Y
<br />CITY. tOW'N W lOCAf10N OF DEATH ~ INSfDE C{TY E4AITS i HC`OITA~. OR'OTNER iNSTITUTlON~-Name llf not :n erne+, If HOSa W iNSi tndi afe DOA.
<br />ItSp.c:fy T'es ar Na) ~g:.e sf.eel and number,) ~D.:~aornnr'Fwnr %m. npon.n~iSp«~I,!
<br />,,, Grand Zsland _ ~„~ _5'_es =„d _S t_. _Francis IIOSpi[al____',,, _ I'~ner~h~.
<br />REStOFNLf-STAif ~CCV NEY ;CITY, TOWN OR tOCATtON STRf ET AND NUMBER INSIpE CITY II.MiTi
<br />~ (Spec FZ Tes or Nai
<br />,b ,.ebrasa ,56 Ball ,sue L=enipaan 15d ;',ax 1_69 _ ;,s. 3es
<br />~FATMEZ-NAME FIRST MIDDLE UST .MOTHER-MafDfN NA.KE ~FiRSi ~~~ -' MIDDLE
<br />_ he {Liv.) IP.VZtd P. S::FDLA,~i ,, 2t:,i:c,ORZE G. DGVAL
<br />~hiY.1----------_- _---
<br />'~ i~ M•AS DE{FASED FV'ER iN U.S ARMFD FORCfi? NFORMANT-KAME-R£:A?!ONSHIP-MAIt1Nu ADJRESi ,Si HEt OR R E C wC SITY C1R TD"'«H. StAif. Li1'!
<br />); iV0 ;,girS. Jane Skrdlant-rife-i'.D. Boa 1G9-Dor.iPhan, :IE 6853
<br />~~~SUltAi. ClfMATtON. ~EMOV',kt ,DATE ~E.,ETERY OR CREMATORY-NAME -EOCASION CIT`OR TOWk STATE
<br />Jan.24, i9-3
<br />T=3urial Cedar View f:~-~e_ter~ Dd Doni,han,__:E
<br />-- ° -
<br />fYd ~ SX~', jY2E d tfCENSi NO RV NERA. HOhTE NusF AND A0.^.RFSS ~St Hei iH .. c~tT V O 3*,?F, t
<br />~ ~Z'' ~""' :z~fel-uutier-tedies r.czc a2 t T^ ..11 ~ t ~.ci-Grand IGla^c?
<br />n: ~ ...»..aR. a.a R .- Ta a. ,,. » oc,, a. p a<. a.w ~../u ,K -o-. w ~'~'''` ~ `~'~ ~.n.a a•
<br />_ `zk,. sw..•~...rw._-a _~r13...A.-._~L~it~ '31f kG.,L a -,o s n `~,. ~{!Ct~-Li/~ _
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<br />-DAiFSr`- tA4 ,- T'J-itf7- .•V.
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<br />:]4 ~.~. x
<br />-~-I[C+MtO ODEa.D fia .Y. ~ ~. MONOUNCfD DEADiM ~ Sp- ~P~ONOI+NLEDDEAD "RRONOUNI.FD UFADeFI
<br />„~ D - .3apY ~i rte=
<br />- -SSf1AN COROaiF!'S PNY :AN CK COUNTY ATTORNEY'! -` ar Ta.
<br />2EG15TtA! / / ~ . I, r ~f 4A Y iErrt FC~iStiA !j/ UaT r
<br />F1 4aMES~+. kTf„Y 4iiLE _ f KTER G }Y ~ u5F p UNE FOt f r - ,.. a..n a,.p eww
<br />- - D1SE TO. OR AS A CONSEQ~UFH{E Of ~~• ~..~-,•-:C~~-~_r.Le:.. - _ ..__.~__ ~... n....w aw.a aw '
<br />AUE TL,., Ot A5 A C OiSENCF OF .w•.a o-.+.... e+.r aw iwr
<br />"' _.___ - ________-~ wAY'+ERF _ _-'~.. +-,S LAXi MEFHLD *D UE1MFAi
<br />TART TdEMEY S,GfaFCAR,T rLw,x,oE.f -.,.~,-*w,..,.:.-...n e: » ...w .., n., ....~. ..R `c.~+'*w j.. s '1-..._
<br />R M,G+umr w4`)er: .w ..w.Y _`. .~+."' \aM1NE r-94 ntHONFt
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<br />..•.aeF,.~. Sw~mF wy,:mE " ~AV ~ .,.ti ~.:.. w. a ,,..,_ ---~-~a. - H-_.._;=.:r
<br />» 3A? I- ;t:i ms __/jam r.~ s .z4 rv ~ r ~ ~.. [ ~..~rfu ~l
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<br />1~I~sY`',x~ss-~~t cA~xa~s ~~£ R,~ISET' s=~~ cr 'ilsE *;i<aRas~A
<br />aT,`Ti£ tk£PAB'f~£!v'i OF }IE~"iiTl?, IT C£RTIFiES TI:E ASOL'E TO 8E
<br />A TiCC1iE ~CPY 4FrA!~ ORTvZ~AL ~L".COAL` ~~ FiL£ t+ZTH TAE STA>'E
<br />D£fAkiY?EAT Df ~SEAiT= , St'RI:sL r3F VITAL ST~TZSiZCS: ~:ITC&
<br />I5 THE L£G6b" 3i~FOSZTT?RT FO& ':IT?kL RECORT:~.
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<br />nZ£EGT:,`R Ot~ =YZTn1. STAT1STZvS t.. __-`_SSiBTi.;'Z' S"~'=,TE €E'"iS'"R_zR
<br />LII~LTL2~, IE°£Sx.AST~ )ss„ec February 1C~, '.~7c~
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