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STATE OF NEBRASKA-~EPAI;7'MENT OF HEALTH
<br />Bureau o(Vitd StrELtier
<br />~(~~ ~~~~~ CERTIFICATE OF DEATH~O ' <<.-
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<br />rrwN SEX DATE OF DEATH : •
<br />DECFASfD-NAME runt
<br />Clifford Kenneth Larson 2 P? y. Julv 7 1 0
<br />DATE Of lltfN :.rover«, w+, COUNTY Of DEAM
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<br />Grand Island ,ayes ,,. Lu~neran Hospital
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<br />CITIZEN Of WHAT COUNTtY MAtIIFD. NEVER MAInED, SUBVIVNG 510USE i n rrn, ere ,v.
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<br />22 riildred ~:?olf~ram Larson
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<br />CfTY TOWN CM 1OG110N Oe an corm STREET AND NVNIEt
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<br />CharlesT Larson 2e. ?`acv ^nde~son
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<br />FMDAWEtfr fIONATLIIF J UCENS( NO. tEG15111At-SIGN URE - / ]Y , r , % / '
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<br />THIS CBI}'fIFIES THE ABOVE TO BE A TRUE COPY OF AN ORIGINAL i
<br />~~ ; ~„ `~ERT ~,GA'rE ON FILE WITH THE STATE DEPARTi1~IENT OF HEALTH, 1
<br />-'°,_} BIiRE~I:'~F VITAL STATISTICS. WHICH IS THE LEGAL DEPOSITORY ~
<br />+~'BUR:d1ITAL RECORDS. -~
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<br />DIRECTOR OF YRAL STATlSTK:S AND ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA Issued Auo. 17. 7970
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