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<br />RACE-le.g., White, Black~OR
<br />~-- Indian, ek.l!$Pec;lYi +~hTl'll to GF
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<br />STATE Of NE~BRASMJ4--DEPARTMENT Of HEAI.Tti'~
<br />~BI+URyR7EALE~! Of YITAL STA?15T~cs
<br />- MLCCERI ~T~.. -'U, r..._., „;SEX
<br />Eu,~zie Willis ~2 bale
<br />i(..g.0°I;on,FM.icon, ~~AGf-bub;n+.doYT UNDER I':fAR
<br />r,,ci1Y) I (Yn) MOS. ~ DAT$
<br />l: aTl I. CJE I,.
<br />Octcaer 1tI, 1:479
<br />DER 1 DST DA fi OF BIRTH (MO., Do,, Yr
<br />0.S . MINS
<br />;_ Fiav 29. 1923
<br />CITY AND STATE OF BIRTH (I! rwf in U.S.A., CITIZEN Of WHAT COUNTRY MARRIED, NEVER MARRIED, NAME CF SPOUSE (U~de, gave mor~ o d,ms
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<br />°T Grand Island ide WI WED, D)YO CED (Spe<+!y)
<br />~larrie~
<br />iri2sgaret Louise (Luke) /
<br />USA
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<br />SOCIAL SECURITY NUMBER USUAL OCCU PATION(Gi.e kind °/v.ork dens during most KIND OF BVSINE55 OR INDVSTRY GOUNtt Of DEATH
<br />72 508-1b-56;1 ,]° i{ruck giver I„bCargenter Paper Gam. Hall
<br />Cltt, TOWN OR IODATION OF DEATH INSIDE Cttt IiMITS HOSP17Al OR OTHER INSTITUTION-Nome (IL •ror .n e;fher, If HOSE Oa INST. Ind;wre DOA. '
<br />
<br />' Grand Zsland
<br />i Ab. , (Spe<ih Nc/
<br />,.~. des Rivrt<e ~a CWrpor;n"r!F-• N.,I parse«ISa«Ayl 1
<br />,.d. Yraa"i. '' 7tn Street ,,,
<br />Rf51DENCE-STATE~COUNTY~ iCItt, TOWN OR IOCATION ;STREET AND NUMBER INSIDE CITY IUArtS
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<br />k Grand Island
<br />7th St
<br />1704 ~
<br />~ 15i°`'FYl~es "°' ~
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<br />,56.
<br />isp. Tde .
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<br />fATNER-NAME FIRST
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<br />' John 1'~il MIODIE lAST MOfNER-MAIDEN NAME FIRST MIDDIf U3~
<br />liam Williams j,,. Susie Xocum
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<br />WA$ OEC"E,A~5ED EVER tN U.S. ARMEDy fORCES7 I INfORMANT-NAME-RELATION541--AUItING ADDRESS (SnEEY O. tI~S?B24d',`?{FPY°H.! S:]a9:l.
<br />•T~ea 4j4~Ia~%22~43-3/8I4~ ~,9 Ntrs. MarCaret L. 47il1izDts-klife-1704 E. 7th St°, Grand/
<br />BURIA4 C•emorion, Removal DATE CEMETERY OR CREMATORT-NAME LOCATION CITY OR TOWN STAiE
<br />20.. Burial 120610/17/74 2«.Grand Island (City) I2gd. Grand Island Nl;
<br />i EMBAI®kER-51GNAI E ItCENSE NO. ~r~o fUNERAI HOME-NAME ANO ADDRESS (STREET Oe R 1 D NO. CIn OR tOWN. SGtE. ZIF! 88Q1
<br />27 ~ ~ 22. Livingston-Sondermann' a 505 W.Iioe , Grand 1 d iQe
<br /> beu 1 no- ledge, dwM «<urrad «r M nme, dap and plo-.a end due Iu rM. I a in .Ilan nder u;e a+;w my e < n.d e.
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<br />:> DATE SIGNED (Mo., DoY, Y..j HOUR Of pEATN _ ~DAT~ N (MO.
<br />oY. Yf.
<br />,e=
<br />~ <a z `o
<br />. 2]6. 27<. M ~ Ub'Z 1.6. 2~c. 9'15 T)eM
<br />E f DATE Oi DEATN (Mo., DoY, Yr.) o'op PRONO LACED DEAD PRONOUNCED DEAD (Ho-
<br />
<br /> 1]d. 24d. 2de. M
<br />NAM E AND ADDRESS Of CERTIHER (PHYSICIAN. CORONER'S PHYSICAN OR COUNTY A TTORNETI Hype or Print
<br />
<br />Grand Island NF:. P.O. Box 3b7
<br />' ~~ ~~ hl armor--j~e~- , hE~ri °f~ l ~l S_
<br />R#GISTRAR OATEJjE1=EIV ED BY REGISTRAR (M°., D°~r. YrJ
<br />26° rs~y,ahn.I~CGh/~ ~.~ ~scY-`~•~.c.l„~?x! 2 /~~~~~U os ~ /jz ~' c-
<br />,,, 7~ 7. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER UNF. FOR (o), fb), AND (<)) In....nY b.I....n pnar end dwd
<br />( PART
<br />t lf^nrnT'IArLT orrl TTSi nn immediate
<br />T DU ' TO. OR AS CONSEQUENCE OF: F InNr.ol bHrew m„r o-"d dwrb 1.
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<br />ibY
<br />- DUF TO, Ol AS A CONSEQUENCE OF: Inr.nW befwan w t and dwd. 4
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<br />' PART fuFKANi CONDIfiONS-Cwdirio-« .wrribnriwg b daorh bat wr ..tared VYfGN~NCitN ILHE FAST ] MONTMSr I f$pacOlr Yar « Ha) : FYAMIHER ORFCORONTO MEDICAL
<br />11 I IfSp«dY Y.r sa Naly_ _
<br />I .l ..., ~~ I <n -- f
<br />ACCIDENT. SUKWE. f10MJCrDE. UNDET, I DATE M INIURY (Me.. Da,, Yr.) HOUR OF INIURY rDfSCRIRE NOw INLURY OCCUtlEO ti
<br />OR PENIRNG DiVESIiGATgN I Sq.•Ly) i fl
<br />]DD. i ]Da. ]a. M I ]od. ~
<br />RLYRTAi W WR n.ef a ~wuRY- M ha.., la~`-,., w«e, 1«+erY. tocnnoN sieEEi oe RF.D. N.. cm oR iOwH iTArE -
<br />YSw~IY Yq « N.1 i °lr:i. b.dd.ng..w (sP«dYl
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<br />W~I'Fr~3 ~'~t~S=~CO"~Y CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />Ii~E iIE'~AtRA~Ei:T OF HEALTH, IT CERTIFIES THE A$OVE TO BE
<br />,A L~~UE GftP'fr~ 0°F AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />•D;~d'ARTMFi,~TT;~~' -HEALTH, BUREAU OF VITAL STATISTICS, WHICH
<br />IS`~,r,~H~~~•L'E~,A~L~`'DEPOSITORY FOR VITAL RECORDS.
<br />., ,. J-__ ~ ~1O
<br />DIRECTOR OF VITAL STATISTICS AND ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA _ _ Issued October 30, 1979
<br />
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