|
j STATE OE NEeRAS1Ul-6FPARTAEENi Df ]IEAtTN
<br />6UREAIi OF YItAI STl1TISTIt:S
<br />$,®._,,,';~~~~L CERTIFICATE OF DEATtf f - c
<br />.TxC 5 M1Cd<Ca3t I
<br />SIAIE OE BNtTN fll n•! in U.S..(., CIIIFEN Of WNATCOUN
<br />'`~ 'T~'
<br />rd
<br />` E Artcad~ NeU~f ha gyp. tt.s. I nl xea ,1. vouce r<I. sete~ . .
<br />]OCUI SECUeITY NUM6E! USUAI OCCUMTION (Gin EiiddrwEA«dPnPp P.PN EIND OFOF lULNES]ORINWJSTlT COUNTY OP OFATN
<br />Pl.PN.np l~h. •r•n if r•tir[d)
<br />to 506-'0-3 4d uP 6taart e~f (i~eM!.i.n •''' lab- Q T.P. ca.e.t~E
<br />-
<br />---
<br />C,T,./OWNOltOCATION OE DEATH INSIDE CItt IWIT$ Nt!]PI7Al OE OTNEE INSi1TUT10N-Nuw[fIf.NTiP,E(6Pr, tlNOY OE IN3i.
<br />brLaMaDA:
<br /> fSP•rify YOlw NPI pi» P[landn•wMT) OrPON'°VErr'M.Y'P•Mq(fP.stlYf
<br /> "~
<br />-
<br />CITY, LOWN OEEOCATiOIt ~
<br />[FSIDfNCE-STATE COUNTS STEEfT A INSIOECOTUMIti
<br /> (SP•[iFr YnwNeF
<br />~~p
<br />1]f.
<br />15P. FJebral,Fta 156. FFa.EY
<br />T-
<br />- 13d. 1]•. .
<br />NM1E flpSi MIDDIC U
<br />A NE
<br />` TNFt-IMIDFN NAME ZEST MIDC!
<br />L ,P. CEi.~6nad FfaPP Fn nvTn ,a. dlonna Ze~Rxt hktoRen
<br />'- WAS DECEASED EYE[ 1N D.S. AEA(ED lOlCf ST 1INED[MAN!-WAIN[-[TUNVN>nrr-MANrn.• wuu•[>3 ryrm(3 W [ T.u. irl
<br />~ ITw, ». w vn1111I n.. p~~• w rnd Pw. N w..,.N ,
<br />If uo i _ _ ~IP. FfRa. Ttoa.i.e SI. FReeman-W.~ a-62B E . Phoen~.x-Gland I~sfand
<br />y BV[IA:, Crtmpiion, ]emPrPI DAE CEMFtEn OR ClEMAiOlT-NAME LOCATION CITY O4 TOWN ]EASE
<br />Dec. 6~~
<br />_aw. 6tEA•Ca~, ao6 'a]<. C;rtand IS£nltf~.lemC~P.ltc! ~- Gland I.4Zand. uetzxaAhA
<br />EA1pA1MEP -SIGNATUE! i lIC[NSf NO. FUNFEAI NOME-NAME AND ADDRESS nTMft OII [ f O NO.. [IR O[ IDwN. STAiI. i111
<br />al `~~`~,~._! '!7 a. a+'•`'= ~Y~be£-Bf>!L£ert-Geddes iF23 U1. 2ndL Gland Ieland. NE. 6884
<br />~.- .^-1; ~M b.N nl ., 3»NN\w a»q •J •I Nu s«, dr, e•J p4.• •.. d rM T 0. d,r \ Air N >•Pnr•M» •Mfw i•w.APPMrn, inwT i.i» MPq wnnM x
<br />~ n N.1 uu~M it H«. . N PIw, r. J.• r M .••wN1.wN.~
<br />! t° pAT[ SIGNED (MP'. OP' I.) '~ • T `NODE OF tl TN~ v~ ~ Il C ]d ~13:,wrv •~T,J.o'r. A
<br />'°`t dam 12/11/79 Iar. 10:07 a.,,_ 4..x a.6. 1a4, 10:07 a.M
<br />- ET f OF DEATH /Me., Da Y. Tr.) O~ PRONOUNCED DEAD PRONOUNCED DEAD(NPw)
<br />-` v .December 3, 1979 L 9da. 11~~/79 ad• 10:07 a.M
<br />NAME AND AODlESS CF CE4alFIE! (IHY51[IAN. CO40NEC] PHYSICIAN OE CO:INIY ATTORNl37 (tYP• w I.iM)
<br />----- ----,, .:~
<br />! U
<br />+-~ oEC I~ ~~7s
<br />.
<br />t'r:-%). :. ~ ~..-l. f'f n
<br />]SP ILp»w..lP
<br />I 966.
<br />fLAU IfR IINf OR (P), Ib), AND (r})
<br />~)!. YMMEDIATE CAUSE NE ! ONL
<br />~ I.y,»I \...•...,,.r.,.i J»q
<br />Pw[T
<br />t
<br />btET.ir,:1c E,i~.fa~: tT~2t'r~rt~lur~
<br />i4 h-Ys
<br />DVF fGS-OE A] A CQN]FQUWCE Oi: _ r..i br.... ».N eJ J»q
<br />i
<br />,\, l~tCefP~Ll4 ~~XlC1T7 4 ~ }~
<br />i
<br />_
<br />DUE 10, Of AS w CONSEOUfNCE Oi,
<br />~
<br />~
<br />~
<br />
<br />' r
<br />.w•
<br />br.rN \r»•• •d J»q
<br />~ti!_/
<br />ttEu(:y~~+
<br />:r.
<br />ikllr~~o-~l~I•~Er~rzT~;tnr~.~ tr~s}n
<br />~ : Sam,..
<br />..I
<br />r_fAE~~~ HGi uKY+I CONpigrS-<w.w....+w..+•p r Jw. b.. w.W TT+.St +p 1'rY M i DIOTST «!
<br />NIDNANCi N IXE :~f~ 1 gOidtHET Is•rJ, iw r ww3 C„S( rn ISNP t0 uP~CM
<br />*[ W CO[Ow11
<br />"
<br />n:no(«I, suw~aE. rwNlcwE. w+wT ~-'wtE or-PUwT lw.. mr: *•! Nou[ a ~N,P[r
<br />t
<br />t
<br />-
<br />a sc®xi Na
<br />iiuui+accu[uD
<br />W NN:tiNO fN.t S
<br />lGA
<br />WN NI•r
<br />r%
<br />~xTi. M~
<br />ws
<br />]DP.
<br />]w. _.
<br />_ e
<br />~,____
<br />~
<br />•.~ r0# ,yAS! _ PMDFY-M 6~e_I I•PwT. '104AFW,1
<br />a tSrwdr TaT t N•! ~ •H.e b.ild.nP, W IEPwdr! SSp,I W [I P uw -In Da IOWN STALE
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASTfA
<br />STATE AEPARTMENT OP HEALTH. IT CERTIFIES THE A$OVE TO $E
<br />A TRUE COPY OF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />DEPARTNENT.OF HEALTH, $UREAU OF VITAL STATISTICS, WHICH
<br />IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DIRECTOR OF VITAL STATISTICS ANt? ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA Issued Decemaer 2$, 1979
<br />`-
<br />
<br />
<br />
|