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<br />,' STATE OF NEBRASKA--DEPApTMENT OP SFEALTH
<br />80°-- ~ ~ ~ ~ Q ~ pUREAU 7F YITAI STATISTICS
<br />CERTIFICATE DF DEATFE ~_~~.
<br />DECE NT-NAME i1R5 MIDOIE LAST SEK `~DATE OF DEATH (f•to.. Oaf, Yr.)
<br />Harold Theodore Randolph z. male 31 August 1, 1980
<br />RACE-(e.q.. White, llDCE, Am«icen OMGINfDfSCENTb 9~. Uniinn, Meekan, 4GE-InN efnMer VNDER 1 YEAR VNDER i DAY DATE Of pFRTN (Me., wy, Yr.)
<br />Indian h3 (Sp«ify) German, eh.) (Sp«dT) i ; (YrE-) MOS. DAYS. DAYS IHOURS - Mt- M1N5
<br />white unknown ~~ a ~._ 64 ~.. L_ ~. FahnTaT-o 1F_ t4tti
<br />CITY AND $TAS! # !IlTN (d es1 in V.S.A., CITIZ~N# wNAT CGVNTRY MARRIED. NEVER MARRIED, NAME OF SPOUSE (1} vih, give maiden nomr)
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<br />Nebraska
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<br />SOCIAL SECVRITY NUMlER VSUAFCICCUTATION (G:.e llnd eltrorE don. dv~ng moY KIND OF BUSINESS OR INWSTRY COUNtt OF DEATN
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<br />505-20-2989
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<br />CITY. TOWN ORIOCATION#DEATN INSIDE CITY lIM1T3 NOSPITAI OE OTNEE INSTITUTION-Name ft(nor in NlAar, r OSI OK INST. I,dceeeE 90A.
<br /> (Speedy YeF O, Ne! 9're Ytreet end number) O..rver:anVE.n.. tm., Inevt;wrf5pmdt)
<br />It6Grand Island ,k, yes „d VA Medical Center ,,, inpatient
<br />RESIDENCE-STATE COUNTY CITY, TOWN OR ICK'ATtON STREET AND NUMEER MSIDF CITY lIM1T5
<br />~ Nebraska Hall
<br />Is.. Is6. ,s. Grand Island
<br />tsd.522 North Walnut (Sp«ityY««NO)
<br />Ise. yes
<br />A !-NAME MIDDIE 1157 MO NEB-MAIDEN NAME FIRST MIDDLE LAST
<br />(dec.) Samuel Randolph , (liv.) Mrytle MerrimF
<br />.,.,,.,.-m.:.~~o nw,.oo ra.ff. of ....p. No. cm o. roWN. suit. nq
<br />a... w, n.~~r.F>I(~x ,... t•..... are a°.<. N ....;..I 68801
<br />ISesJVHy4-13-4818-31-6c jl9Eva Randolph wife 522 North Walnut Grand Island NE
<br />Er lUtlA4 Ge..'orioe, General DA CEMETERY OR CREMATORY -NAME ~ IOCATiON CITY OR TOWN STATE
<br />Aug. 6, 1984 Elmwood Cemete
<br />».. tu'ial ~. ra ry zgd S t. Paul, Nebraska
<br />E E F ENO. i FUNEGI NOME-NAME AND ADDRESS , . ^ST[fET DYE . p NO. CITY OR tpWN, AtllF, ZIP\
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<br />(DAT[~uIGNED(W 'Hs ~N AT I is •'SA 1 NE (Me Dor, r) U 4
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<br />~Fd :a6. August 6, 1980 Izk 11:30 pM iga°~zte. I +<
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<br />E_ ~D1TE 01 OfATN tMe., DeY. Y.,) ~Ia~O iPRONOUNCED DEAD ;PRONOUNCED DEAD(Now/
<br />Au t 1, 1980 =`o• ~tAte.. Dey, rrf
<br />_ ~ T>.. 9~ ° ITad. ETA M
<br />NAME AND ADDlf55 # GElTNIN (PHYSICIAN, COlONEtS INYSICIAN OR COUNTY AROENEY7 (type e, Pnnr)
<br />xDennis A. Hazdmar., M. D., VA Medical Center, 22(,1 ~;. Broadwell. C;rand t~tanYt. raT-F,ARTtt
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<br />7T. 4M{!W~ ENifR ONLY ONE CAU PEE UNE }Oi (al. (6). AND (.11 I nwr, oW d
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<br />ACQD[M/. SDICp.lFD1~[10E, UND[t.' pAlf tM rN)tM~ tMw. Dom. .. I 'MOUE Oe INIU« DfSCbtE 1,0'.' IwUt+' UCCUSffD
<br />p P[Yf9gIC mIYESRXI1TtON FSe.r.tN '
<br />50t. '; 506. ~'~ )OY ~ 7Dd
<br />tIF 'f WO< e1AC[ OI tN"JET - u inwr aem. r.n.,r. '.IOCAteON SiKEI OE E . D w
<br />herd, a r NN ~ Nfv-A tuM:nE. r„ lFwah: ,~ CITY W TOWN STATE
<br />iiHEN'~T~.(5:1~~YTY"CARRIES TAE RAISED SEAL OF THE YEBRASKA
<br />STA~,~11EYliI'RTP££i1T',OF HEALTH, ZT CERTIFIES THE ABOVE TO BE
<br />A; TB~1; -Ce~X QF_:,eT.IP; ORIGINAL RECORD ON FIL€ :JiTH THE STATE
<br />D.~JtR~-ILEN~_O`F`aHEALTH, BUREAG OF VITAL STATISTICS, WHICH
<br />I'S'.:~,H£"'•L£f+fi~L ~BgO¢ITORY FO1R VITAL RECORDS.
<br />DIROC ? ,'0F'~TTgI, STATISTICS AND ASSISTANT STATE REGISTRAR
<br />LINCOLN; TdEi{ltASKA _ Issueu~ September 15, 29$~
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