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<br />CART I. - DEATH WAS C/USED !Y: (ENTER ONIY ONE CAUSE vER trNf FOR ; , (6), AND (+)I
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<br />AGCtDENT. SUKIDE, HOMICIDE, 1 ~ woxw .• HOUR HOw INJURY OCCURRED 'rxrN x•.wr or w,u•+ w rMr ~ w r•, x, rtew I• I
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<br />CERrifIER-NAME I o, wn rS-GN TUR ~ II O,IiE 51 ED •I
<br />,,. A. E. VanlTie 1'T. D. ~,,. ICl Z-. I ~ rF.. , t.~ I 1 ~ a•rh l oY_ J I,,, ~~ 4~r ry..
<br />•~ CRFMATIOH, IEMOYAI 'CEMETERY OR CREMATORY-MAMF IOGATION can o! rowx s.+H
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<br />- uTF r«, •R I EUNERAI HOME-NAME AND AOWE55 ~ sf ! •.r o., c n o! ro s +re. n. ~
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<br />EMBALMER-5!(.NATURFB LiffN~S~F ENO. T? /+REGISTRAR-StG.va .~ .~,g/ I~ // It,RGA,~I } ~!
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<br />~ `'`_-'_WHEN ~$YYS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />`•`STATE,_DEPARTMENT OF HEALTH, TT CERTIFIES THE ABOVE TO BE
<br />:;~~,~"A '~~IE'.CO1?,X OF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />~~EP'A•ILThPEPITT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH
<br />~;~ •IS-._TAE,.I;tEG'AL DEPOSITORY FOR VITAL RECORDS.
<br />.DIRECTOR OF VITAL STATISTICS ANI' ASSSSTt'~NT STATE-REGISTRAR
<br />LINCOLN, NEBRASKA Issued July 2&,-1980
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