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<br />STATE QF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL pF THE NEBRASKA pEPARTMENT pF HEALTH AND
<br />HUMAN SERVICES, IT CERTIFIES THE BELpW TO BE A TRUE COPY OF THE ORI~ GINA,~ ~~~CQRp ON
<br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH ANp HUMAN SERVICES `-""'~'
<br />pFFICE, WHICH IS THE LEGAL DEPOSITORY FpR VITAL RECORDS. ~ ~; "" ~`~ ~~'-~ ~
<br />DATE OF ISSUANCE ~,
<br />~sTA~NL~~Y7 goPER ~ .~
<br />FEB ~ B 2010 ~ ~ ~„ ~ ~ ~ ~, ~ ~ ';ASrs'ISTA~VT S~'ATE R~G"ISTRAR
<br />`.C7F~PXI~fi(l~ ~~ALTH•d~yP~
<br />LINCOLN, NEBRASKA °H1JUN,gN. I~by l...r
<br />~ „....._
<br />STATE QF ~ Y1TAL $7 Of HEAhTN L ?~ '. r/~ ~~ n y.. t •
<br />~;~r ~~'~ ~~1~~957
<br />CERTIFICATE OF DEATH i -1 , ~ v (, ,
<br />1. DECEgFAIT -NAME FIRST ~ MIDDLE LAST 2. SEX 3. DA CF ,. TH , (AWnpa Lyy.YAr/ .
<br />Iva Mama La her Female November ~ 21 1
<br />4. CITY AND STATE OF BIRTH (M AdI N U$.A, Aurre ppynhy) Sa. AGE - Leal a. DATE OF. BIRTH ~(orlfl,
<br />dihhday ( ~: Yer7
<br />IMra.{ 6b. MOS. gArS Sc. HOUR INNS.
<br />Dannebro , Nebraska 79 '
<br />T. IAL SECLHiTV NUMBER aa- PLACE DF DEA7N g~' . ~ PIovemhe r
<br />-?PITA~ C7 1np+MMr 6 E91Dugahwa ~ DOA
<br />~ 26-oy 1 o a o_ THER: a N«a,~ I~r,. ~ R..~. ~; onK (s~;rrr
<br />ACkITV
<br />.Y- - Name (Mndf grek~pn, yAM ahaef antlnwnbrry &:. CITY, TgWN OR LQGA7IOH..'~ DEATH ~ .
<br />-.. _.. ._"-~ --- .... _- ~ - .._ - ad. Y YYe ~ -.;M. COINITY QF DFJITH
<br />St. ~IranC~B Medical Center Grand Island Yes
<br />NL RESIDENCE • STATE ib. COUNTY >k. CITY, TOWN OR LOCATION Yd. STREET ANq fAJI~ER /Nrckah+g Lp Ca1M p,- Ya~E p7Y
<br />Nebraska Ha11 y t (aPiaayYNabrAty
<br />T0. HACE - (a.Q•. W7rla. BW:k American Indian, 17. ANCESTRY le.9•.naAan, Maxlcan~a0arman, a1c. s lan MARRNiD,NEVER p 9 R t BPOUBE
<br />wc.l (saeciyr r.~v~M'r wlnowED, DrvgRCED (sprclyi ("` "'w: ~"a a*~~ ~raalt
<br />White American ~~ Mar iec~____._ John J. La her
<br />taw USUAL oCCUPATgN (G/rr kiM d enrk ddne during mast tAb. XHYD OF BUSMIESB INDU5T RY
<br />a1 aantrrp AYA ewn r+rwinrdl ~ ~~ EM+nNnlarY ~ ~ laT~ I
<br />Homemaker ~~~ G+•N.n~«:•I
<br />Uwn Home 11th Grade
<br />1a, FATHER -NAME F T MIDDLE LAST 17. MOTHER - MA.DEN NAME FIRST MIDDLE
<br />LAST
<br />I"rank NMN Fenton Pearl NMN ~a~
<br />IB. WAS DECEA'8ED &VER MY U.S. ARMED FORCES7 19. INF(~RMAN7 -NAME .. NIAILMIG ADDRESS (STREET OR R.F.D. ~ J-. CITY OR TOM1111, 1
<br />IYsa, ro, a wrt.l IH Yea. q~w war end dates d eerY~ceAS V OOCI
<br />Nc ------- ohn I.a her, 3946 Reutin Rd. Grand Island Ne.
<br />20a~ Wenrlk>1LRenldral, 200. DATE 21k. CEMETERY OR CREMATORY .NAIVE 211b. LOCATION CITY OR Tp'AM STATE
<br />Burial Nov. 23, 1992 Grand Island Cit Cemeter Grand Island~Nebra>~ka
<br />?T. MER • i NO. ~ 22. FUNERAL HOME -NAME AND ADDRESS (STREET OR 0.F.D. NO. CCTV pR TOWN, STATE, ZIP
<br />~6$8Q1
<br />ivin ston-Sonderm nn C•5 ti+I. ~toen~g~„C~~,,,~,~~,~~~~
<br />PART MNAEOIA E USE IEkTER V ONE CAUSE PER !-INE FOR !s•1. Ibl AND Icll ,
<br />~ ~ M1larval baA.en O11aaI aNe a~
<br />I
<br />C+ei~
<br />A
<br />' Inrwl aewau. Barr awN wr
<br />- ra/nMl Uasre.n gnaw aed daa/n
<br />PAAT . -'~.. ~~T ~. ""~ • ~"'° - `°`apO~'~ wnnauwq aeaMG - PAF1T N1 IF FEMALE f1r ~
<br />', a ~7aae: tra rid r P5. YM48 CA>!E
<br />sv rr r.Ai ;.
<br />a PREGNANCY M} TFIE PAST 3 ? (SPaery a. ~ ~~~ ~
<br />2aa. ACGlDENT, SUX:IOE HgANCtDE, t}NDET.. tab DATk OF MLA7RY (Ad[~..t7'Iy. }'r./ 2aC. HOUR OF INJURY 2a0. FIgVd W,N-IRY gCCUR11Eb
<br />Op PENgING WVE.4TKiATX]N !5(yeay;
<br />_ 1
<br />2W. e6AMiY AT WDAK 2M. I'f.ACFg• eKY (Spreiyl r~ ~ GKnrV ~4. LOCATION STREET OR R,F.D NO CITY OR TOWN aRA
<br />lSpecNy YM a Aa; alarTe ^-"---^
<br />2ra. DATE 4F AEATu IlAfo., Ms Yr! 7aa. DATE 91C+NED (AAp. aY, Y•.1 2Nh TIME t7F DEATH
<br />Novr 21, 1992
<br />270. BATE SSONED (Mb„ Dry. Yr./ 27<. TMIE OF DEATH 2dc. PROHOUNCE6 DEAD (MO.. py Yr,l 2Nd MICNOUNC!<A DG1q gywry
<br />~ ~
<br />~~ ~f Noven>~ 4, l99 1;C7 ;,M r..,
<br />~~
<br />770. Tn thr bep al w r ~cw+ad s1 U+sylr+.. ~ PMe. uM dw b ~M v
<br />sr `~(^i1J ~. on r+e ww a ar«nw+rr0n andrer mawgwon, ~+ .w aowen e.r~ eaa~r~+e r
<br />~. b the Mlrla. 9aM alw p1acN pd due to xia cauaala) sA1Mad.
<br />and T
<br />r and Ties
<br />79a. DID TOBACCO USE CANT THE DEATNT 3t]e. ORGAN OR TISSUE DDNATh 4 BEEN CONSIDERED?
<br />306. WAS CONSENT pgANTED~
<br />VES IrG C7 UNY,NDWN ~ C; YES Ng .
<br />;' r!"sS NO
<br />91. NAME AND ~UfD~B ERTIFIER (PHVgICAp CORONER'S PF1r$1CAN OR COUNT'T ATTgRNk"1'1 (Type a Print
<br />•`r
<br />,~ ^John A W aver Jr. , 80Q Alpha Grand Islam.:], N~ 68803
<br />~~
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<br />THIRD SUBDIVISION IN THE CITY OP GRAND ISLAND, HALL COUNTY, NEBRASKA.
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