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Q STATE OF NEDRASKA-DEPARTMENT Of FIEALTX
<br />E.7o~ 1.1 n ~ ~ L+ (~ BUREAU OF VIT11L STATISTICS
<br />lJ 1l l7 V CERTIFICATE OF DEATH ~ . ~; ;,
<br />DECEDENT-NAME N T MIDDLE u,6T SE% (DATE OE DEATN (MV.. Uo Y. !. /
<br />Cave 7I+Iale ~,- Sen. a, 1980
<br />John
<br />RACE-fa.y.. WkiN, Rink, AMVIk~N(DE$CE PiKa.~., bvOvn. M.+kan. AGE-Iml E:nWvr OS EE ! DAYS I NOUR$R ! ~ NS DAif OF li1RN[/MV-. Dv,, Yr /
<br />lud:en, Ek.)t$P•nfY1 Gulwwn, •I<.7 ($ '!) ' (Yn.) M ~ ^'' I 6 1°0
<br />CITY ANO STATE Of RIRTk (N ve! in U.SJ . ^ CITIIFN OF WHAT COUNTRY MARRIED, NEVER MARRIED, !NAME OF SPOUSE fli.N•, pi.• mvld•n naw•1
<br />•Ni1 WIDDWED. DIVORCEDfSPe '!yl
<br />'ver Tde. g J. S. ;:y ~iever T~iarried ,. 1Vone
<br />w. <µtdood
<br />SOCIAE $FCUfITY NUA{RFR USUAL OCCUMTIONfG~.E Uvd oi.erY davdv..ng nwsr (KIND OF RUSINES501 INDU5IRY COUNtY Of DEATN
<br />~/ er.e.yq rr.,. .[..n,g1 ni nv I ?+2,~1
<br />5Q&.,,~ ~G76 i>o. t R.1'Iil@r L,: .~ oOCT{GL<-Yl .' u i 1136. F&T lb
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<br />CITY, TOWNOR 10CA710N Of DEATN INSIDE CRYIW]i$ NOSTITAt OROYNEE IN$tttUTION-NPw•(ii n•!.^«rM.. ~~~vsr"~E~N?TU.'d.penDir'IAt'SP.<~rY+
<br />I$PKiIY Y•<er Ne/ yr.u gnuwMr), r
<br />,.,. Grarui Island I!K Yes ~l,dS~:e%'rni'iois redical Center !!., Inpatient
<br />RESIDENCE-STATE COUNTY 'CITY, TOWN OR LOCATION STREET AND NUxRFR INSICE GIY UMITS
<br />f$p•<~ Yetw Ne)
<br />t$P. N@. ub. Ha7.1 lik Wood River ~lsd Rt. 2 I.s.. ~~o _
<br />A N -NAM I[ MIDDIE U i ,MOTHER-MAIDEN NAME FIRSt MIDpIE U T
<br />Michael Caver~y i „ Delight Kerr
<br />T
<br />WAS DECEASED FREE !N LLS..ARMED FORC EST ~ INFORMANT -NAME- RffAT1ONSNIP - MAILING ADDRESS !STREET Ot E E D NO. CITY OR TOWN, STATE I
<br />o... n•, •. ».! l nl .«. E.» -_• en..;_•• ~' ««... ,r a i var R Tde 68883
<br />n. I 'roT; -'
<br />RURIAE C.R•vtitro. REwewi DAT ;CEMETERY OE CRfMa ORY-NAME .t CATION CITT OE TOWN STAif
<br />70i ~i~ xyb. -8-80 ', 7D<. St. P? 's Cesn°te ~'70d. blood River,- Ne.
<br />EAIYIYER-$D:!/A1~F A 11GENSE NO. J '~ fUNERAI NCWE -NAME AND aDDRE$$ STEER OE I D N0.. CItY OE TOWN, STAif, ZIF! / 8U01
<br />,,. ~7 77 - _ e d IslandUJNe
<br />n - DATE SIG E (MV De Y. Y. ! HOUR Of DfA1H
<br />txlTE OF DEA A4.. De,• Y..) <
<br />'a-% ', 7Ab M
<br />~ 7AV.
<br />1 S 13H, HOUR OF DFALN ~ u i PRONOUNCED DEAD '~ PRONOUNCED DEAD (Neu<1
<br />{~ , DAII -. De . Y.. ~ t t S ~ (Me.. DoY. Y.) ~ « i , w» <..... w __
<br />~I~~E.1- 8 Septeeaber 1980~rk~ 5:36 p.M ~~; 7.<_ A_
<br />ST IT +. IlEw •t ..r.y. e..Il~ //yN i/+...a .w. wan.»In. ~°~° 'ro...w.~evN ..e. we.. w~...1I....i' .a..n.»
<br />_~ ;f...ra r..e. f r.ll.r~ r ~A %~~/.l Pl F'~ ~. ,t-1,"$= ~~__ ,_ :..:- .«
<br />27d rsy.rw ~ it (i Y
<br />~PIAME AMD AOORF S~ CEEf1fItR 1C ~ C N S IAN CQy ATTORNEY) (i p. P 1 ~ r
<br />;d. Je iaiaton °,1. D. 2481} tiJ. Faidley Ave., Grand tslund, Ne. X8801
<br />.DATE RECEIVED EY REGI$TIAR fMe.. D Y. Y! )
<br />NOIiTEA/ //' ~ - r ---
<br />I7. IRWEpATF C4MSF /i (ENTER ONLY f CAUSE PEI LINE fOt fv). (bi. aND f<l: ~ '".n.•I b«..« •»r •M A'.!I'
<br />TAn
<br />„! Acute cardiore irator arrest I".«.I n...... ~ •.. e...
<br />ASAP UENC[OF:
<br />m Acute ocardiai infarction ~"~,~„»,,,,a e..r
<br />DUE tq OR A$ A CON$EOUEMCE OF: -
<br />W rE w
<br />TART MtNCUET CDFIWTIONf-Crf•!:w a•"w•l.~~+p •' •~'• b'^ ^'" •'I"•O ~RfGnurKT I41ht EAbI ] wONiNST 5 TOKt «.. N« lfAYGA E ORlCOEONfR
<br />11 ~' N.._ -'~ 7E 110 74
<br />ACPRttt; 1lKYRf, nOEEPDE, UNRfT.. , DAL! OF bOYRY rN•.. Uw. <.. NODE p INtun OLSCE'Rt NpW ~..]un OCGURRE6
<br />DE EENREIlE lNYERODAIgN l5,<wd<I
<br />~_ I ,yb i T4 M ~. 3Dd. _ _
<br />INISIRY iT WOt KACT OE IN]UET- a. A,wE ...+w. aawY. U7tATlON 5]EEtt OE f 1 6 No CITY b TOWN STATE
<br />lRPriiY Yw « nlel ~ •Nn• i«wnR..a f Spw rl
<br />1 f~ 170T -- --
<br />ttBBN:TH~s`~P,Y CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />6~AT.E DTHfiNT OF HEALTH, IT CERTIFIES THE ABOVE TO $E
<br />.,, ;,~ ~.B~~CCAY-r$F' AN ORIGINAL RECORD ON FIL-E WITH THE STATE
<br />~EIPAx'~DtJENT" Q~g~ALTH, BUREAU OF VZTAL S'TATISTZCS, WHICH
<br />,~$ THE,;,LEGA~""D:£PaSITORY FOR VITAL RECORDS.
<br />_ ~ i ,
<br />. J11~~ ~i
<br />DTRF~: rUp'VTTAL STATISTICS_AND ASSISTANT STATE REGISTRAR
<br />LINCpLN;'tEgRASxA Issued Septe---m~ier ~3, 1980
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