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3 STATE Of NEBR~SMA-OfPARTMENT OF HEALTH
<br />j ~~°` ~ A` BUREAU' O,F VITAL STATISTIICS 7 ~ ~ 8 2 a
<br />CERTIFICATE I1F ElE,AT}! " /c~ ____
<br />_--------__...._----._ __ ------~ __._. c'~ .
<br />~DECEDENY NAME ' fiRST MIDOEE UST SE% DATE OF DEATH (Mo., Day, rr j
<br />i
<br />EttlicRl~' f' 1~ILi~1 2. `ic2Ce 1, 1.fat! 15ISy, 1975 _
<br />' ~FRA~g., Wb~te,'B~ock,Am'c nORIGiNIDf$CFNT(e g., Irai~on, Me on, AGf-toir e.nndvy UNDER( YEAR UNDER7DAY 7DATE Of RIRTH 1Mn, OPy, Y'r} '
<br />- ~ ~ )nd' tlc.!!S~ city) GerPwn, N )fSPSrilY) (I lYn,) MOS. ~ DAYS HOURS i MINS
<br />. 1•i(.t<~ n s. /Unentccut en- 7& ieb. der I~.Ttt~t~ 2 I&9Q~
<br />S CITY AND STATE Of BIRTH ll! nai in U.S.A., CITIEEN OF WHAT COUNTRY MARRIED, NEVER MARRY D, NAME OF SPOUSE (1l..ile, giv..woiden nom.)
<br />~~ pnpr i WIDOWED, DIVORCED (SPecify! I r
<br />B (:kt~taoe ;:ebnahka IP. tI+S+A, .lo. :fcucnteti ,,. l; [th•te Gct,t.eh
<br />^'~ SOCIAL SECURITY NUMBER ~USUAt OCCUPATION (Cite kind of.~orL done during mort KIND OF BUSINESS OR INDUStRY [OUNTY OF DEATH
<br />r Iz 5115-Ay-1194 t, ~~ouetlt•t1a•t GL3 ,z6 t)~,+.u(IIC.thr ,d,. f1aCP
<br />f CITY, TOWN OA LGUTION Of DEATH INSIDE CITY OR OTHER INSTITUTION-Name (I! not in eilber, If NOS( OR MST- IWirea DOA.
<br />Onrpnr.wr/E~w.r. km., i~pa ..n (SPF~EI1
<br />(Spec./Y Yer er No) I gi.e dn~ y n )nberj
<br />~ ~ -' 146 rnQitu/ I-i~t;lttf II.r. f.C' ,ad. t'~fi Xltt.h*~.1::5 Lt7f:t'. i... --"-
<br />s;
<br />RESIDENCE-STATE iCOUN17 CItt, TOWN OR LOCATION STREET AND NUMBER (INSIDE CITT IUAITS
<br />'yf J t. ISPec~lr Yet Or No)
<br />~' ~ lsa 1 ~LU:t.^n,SfL4 ~lsb. 7fflt'_~' IISc. ir.tNl[I Ih~CUiu I lsd~~G f:ttC'.S~i.AJth ~2r.e ~,s.. I.U
<br />T~` fATME -NAME -- fIRST MIDDLE U T (MOTHER-MAIDEN NAME FIRS MIDDI tAgS'
<br />,d. L(JItIS u+ GI LQ;1 I „ A1dt~4t ---~ KQ(tt)EL~
<br />M WAS DECEASED EVER IN U.S. ARMED fORCE$i~INiORMANT-NAME-RFUTION$MIP -/MIUNG ADDRESS 1STREET OR RE.D. NO. CItt~QR _ ESAIE. 2111
<br />~,B`~'e.SiC'.~:TT" 0-1C-iS 1°-~1>-~i19~~sa 1-itvc.~e P,~,~olt-(dx(c-lr66 Kuz~~en.o talae-G2atui ~~~and, t{fE
<br />c -~_URIAI, CREMATION, AEMOVAt P~TF CEMETE0.Y OR CREMATORY-NAME LOCATION CITY OR TOWN STATE -
<br />4Da. litut~t iw~6,f 1~~8 ~_i~r~cutd ihtareci Ceme#eRr1 zna ` Gncuitf Ih+_aeid, 1•lebhw5lza
<br />v EMO E(1-SIGN R UCFNSF NO. y I fUNERAI HOME -NAME AND ADDRESS (S/REEL OR ^ i.D NO. CITY OR TOWN. STATF, 211) ,
<br />~' ~'~ lut ~t~,-r ~~~~~,E~t,^e~C-t3u,t:('en-G~?rt<!e3 1123 t~J. end. Gnmlt~f Th2cuid h1E 8~_-
<br />1 1+ r MV N aE kw+.i+dvo, dwih +rrvn+J ar rh+ nw+, tlPM Pnd plac+ and d.+ ro rh+ Z W On rh+ buaia vl ++owa rian ndlvr ~~pI in aY opinion d+P rrvd ar
<br />t w` wu al acad. ~ i rh+ nna, dok and Pior~ and due a t~wwtr) arorwd
<br />lrZr
<br />y 44a. (LRnora. P^d FMP1 ~ = D ~ 2da, (3i P^er.a and lilies
<br />3 ~ ~ DATE - 1 NFD (Me.. Day, Yr.l ~ ~HI~UR Of DEATH ~~^. SfGt7E (S-M~Pi.
<br /><_.
<br />Esp:
<br />u~ 496. '47c. _ M PW~S 246.) ~Ip ~/O 2k. 1Q~~Q Po M
<br />:; j~ RONOUNCEO DEADfMO., Doy, Y..! PRONOUNCED DEAD (Moor) j~o PRONOUNyCED DEAD PRONOUNCED DEAL.,noor) _
<br />_~ ~ 4Dd. 23R moo; r.P,D~'•/ +578 2 10:47 Fe M
<br />_NSAM~E{pAND ADDRf~S'Of C~RTINFR {RHYSI IAN, CORONER'S PHYSICIAN OR COUNTY A170RNEY) (~ypeJor Prinll
<br />' _ REGi~ p~~f' _ ~ DA E RE E VED I {Mo., Y: Yr.) -
<br />< `_ - ~ ~.~
<br />_ ~ _ 4M.fSfvnehrr+iP 26 _.
<br />27. )MM£OIATE CAUSE t E A' SE E t O (o), (b), AND (<)) berwen eew ad desRr
<br />i PART
<br />.P. coronary occlusion immediate
<br />~i %I Inarwl berw+n enM1n rd aw.b
<br />3~ DUE----- TO. ORS C N$EOUENCE Of;
<br />(bi
<br />DUE TO. OR A$ A CONSEQUENCE Of: ' Iwar.ol berwew uw o+d ae.r-
<br />{<I J 1_
<br />' PART i 3 kOKANT CONDITIONS-Cowdiirona cmM1ibedrp w dePM bvr nw .Naas ARTS tll. iE EENAIF. `HAS (MERE A 4UTOPiT AS CASE REEFtlED t0 Mi Al+~
<br />II ~ /REGNANCY IN THE PAST 3MONIN51 (SMrUP Yp er Ne) ~ E~ tNER OR ~ORONfR
<br />~-. Yei it No i.--~ L4B ':O zPT~r«,(
<br />AC[IDENT. SWCIQE, MOPaQDE, UNDft, MTf Of iNIURY IAb.. Par. Yr~l MOUt OF tWUfr OEXURF Nqw IWURT OCCURRED
<br />OB IEHDINO IkVEEfiDAtiON. 1Sp+<d,l
<br />_ ~Oe. X06. 7Ot. My ~d
<br />- - ~ ~ - YNTURY AY WORK RACE d WYPY- u M , tv.., mw, tnrEa.Y. --~YtOEATiOk SYBEi DR i.E D Ea. EETY OR TOYtvi STATE -
<br />- {SPetdy YxrlM! 7l7 oHfu building, .n (Spxrf,l
<br />SDe- 120(. I-.
<br />~ -
<br />' _ ~ € 3 a
<br />- _ it T{ k ~ ~ ~R _- _ ~-~._._.~_ ...._...~_-._.....-a
<br />}
<br />Wf~Fi~'~BLs t;Y'.CARRIES THE RATSED SEAL OF THE NEBRASKA
<br />~~~€~E~~bePAEi~T s~F HEALTH, IT CERTIFIES THE A$t?VE Tc~ BE
<br />_' = is RII~, C{}~~ '" fir' t}RIGIAIAL ECDRD i}N FTL£ WITH- THE- STATE _
<br />D1~ RTMkNTJ(k~'~)HEALTH, BUREAU OF VITAL STATISTICS, i1HICH
<br />s ~,S'.. tiE ~1Ef3AT. ~~EPOSTTORY FOR VITAL RECORDS .
<br />DIBECTQR OF VITAL STATISTZGS._6~@~,~iST__ _STATF REGISTRAR
<br />LZl~ZN, N$E8A$1GA ~ Issued ~ceR~e, ..179
<br />LOT ELEVEN (ll). KUESTER'S LAKE, APART OF THE EAST QNE HALF
<br />OF THE SOUTHWEST rtUARTER (SW~) OF SECTION THIRTEEN (13), TOtdNSHIP
<br />ELEVEN ~(11) NORTH, RANGE NINE (9) t~IEST OF THE 6TH P_.M., SITUATED
<br />ON THE EAST SIDE OF WEST PORTION OF SAID LAKE.
<br />I
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