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<br />LOT 63 BLOCK 1b, ROLLINS ADDITION TO THE CITY OF GRAND ISLAND, HALL COUNTY, r~,
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<br />STATE OF NEBRASKA
<br />WHEN TMIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMEN~.QI~ ~-f~A'E xM A, l~q . ~
<br />MUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE~ AiINA% ~'pR`p;~l~; .
<br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVIC~S,,.V~~' Ii~~~ 'r~. 's
<br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~'
<br />• ~,.
<br />DATE OF ISSUANCE r. _~,~ .'
<br />MAR 4 3 201 2 010 015 0 0 µ~~~"ANT 7~ REGIS'7~1R~
<br />l9ERAR~A~ ~• At~H`ANQ'
<br />LINCOLN, NEBRASKA H~M,9NS S' ~~• ~r.~~
<br />~'~ STATE !If lil'KA-~PAit1'MEMT bF HEALTH ~.._..
<br />E ~ VITAL STATIiTICS $ 5 ~ ~ ~ ~ r
<br />• CERTlf~CATE a~ DEATH ~ ~ ~ ~
<br />DE E T~ -NAM FIRS MI X N (MO-, Day, r.)
<br />,. Rabert Gayle Horst Male Janua z3 egg
<br />DACE-fqy. WM;M, BSI, Atwgr;tpn ORIGIN/DESCENTIq.p.,Irolien,Agaicen, AGE-LnrRiwwdgy UNDER 1 YEAR NDER 1 Y DATEOiBIRTNIMq.,Oey,Yr,)
<br />Ind;ge, qk.J (Sp.riFy) Ggrwwn, qN.) (SpgcilyJ IYn.) MOS. ~ DAYS . HOURS . MIN$.
<br />.. White , American 2 , 1 ..;
<br />tt ~ TAIL QF \IRTM~M IIeT-TS U. .A.; . - 1 1 .M ~E, 1
<br />NnoDweD, avoRteorspK)Fy) ' ~~ "~' """•)
<br />~lillertan Tebraska q. tl9A 1~, Married ,,. Rita Berne
<br />SOCIAL SECURITY NUMBER USUAI OCCU ATION (Giw tried el weri dgnq dgrin0 wgt3 KIND OF BUSINESS OR INDUSTRY O COUNTY QP DEATH
<br />e/~srti lih, grgA i/nNnd) 0~~
<br />_1$. C~-.~-0r3t~ :,,a ~Gonstructian Co. Owner ,a Dld . Canst. T.,. Hall
<br />GfTY, TOWN pR LOCATION) Oi DEATi1 INSIDE CITY LIMITS HOSPITAL OR OTHER INSTITUTION - Nepw (1-AgT ie frilllgr, U MOiP OR MIST. I./LtgU 00A,
<br />1 Grand I91aT1d (Sp.ti/y rqs or Ns) piw d wd a mMrl O.fp.rl..f/E«-. /~w . wyMi..r (SMr;rl,)
<br />~«. Yes „~. ~~. Francis Hos ital Id.. It'1 tient
<br />RESIDENCE ~ STATE COUNTY CITY, TOWN QR LOCATION STREET AND NUMBER INSIDE tITY WwTS
<br />ISe- Nebraska Isb. Hall. ISc, grand Island ISd. 90~ W. th csp«i Y«aNa)
<br />A ME -NAM I MI 1
<br />LA M ~-MAI E AM 1
<br />, - .~'~•r-est Herman Horst Hattie Mar aret FSrerichs
<br />WAS DECEASED EVER IN U. S. ARME4 FORCES7 INFORMANT--NAME-RELATIONSHIP-MAILING ADDRESS (STRElT ., CITY Oft TOwN, STATl, 2M)
<br />,Y«- wwvgO wYl I (1/ y.,, ,;,y „q, qwd dgrN N w.v;r.)
<br />IB. N ,q. Rita Horst .. Wife • d* W. th • Grand 2 land
<br />BWMAL, Crggldfion, Rgwtevel T ClMETERY OR CREMATORY--NAME LOCATION CITY Ok TOWN STATE
<br />Zoe. Vial ,~. Jan. 26, 8~ z0c. Westlawn Cemete
<br />2nd. Grand Isla ~Ne.
<br />Elr•BA U i U NSE NO. FUNERAL M E -NAME ANp ADDRfS5 (STREET M l.f.D. NO., urr OR TOWN, STAT[. YIP) LC3pA~1 '~
<br />21. ~ (a2 ~ x2 Livin,;ston..Sondermann; 5n5 W. Koenig; Grand I~Vs7OQ1aQQtVnJcli, !fie.
<br />PATE # DEATH (Mo., Dpy, YBr,) ~ DATE IGNED (Mo. Doy, Yr-i 1 N UR # ATN
<br />~.-2~-~5 Z s
<br />2]a ~
<br />} DA IG /Me., Dey, Yr.3 HOUR OF DEATH ~ 2+a• 24b.
<br />~I` PRQNOUNCEDDEAD ~ PRONOUNCED DEAD(Meu.1 M
<br />~-Z~~-~35 { g t_. (Mq.. Dey, Yr.)
<br />~+~ 2X13'_ K ~Z40 ~q~{q M y°O7~zE f
<br />21c.
<br />.~~ Tq /Mq b«r ql w.r MnawlgdR •, dgMh irw~~ ;wq. d qnd pl wd dvq a Ibq ~ Ow M. 6m;~ al gwq.;ngHen gwdlgr iw.rd;yaf:gw, in wr ep;nion dgeM gcwn•d at
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<br />_ 241. (SipnoWn end IiM.) ^
<br />-NAME AND ACDkESS ~CERTIPIER (PNYSI IAN, GO ER'S PHYS IAH OR COUNTY ATT RNEYI (Typq or Pr;n1J
<br />sx w F u~Z~s 1817 w 2nd. St crand Island Neb ka saeol
<br />REGISTRAk _
<br />A` n ~w r ~ D rvED B ISTRAR (Me., Dey, Yr.)
<br />PAR f ER ONLY ONE RUSE PER LINE FOR (oJ, (b), ANp (c)) - InNnvgl gwfgl qwd drrN
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<br />UE T AS A CONS UEN[E OF:
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<br />DUE TO, R AS A CONSEO ENCE pF:
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<br />PART MER fIGNIPK:AMT ONDI IONS-Cgwd:r;gM sowrriYv ~ R M d.grA Yrr wer .•taNd 1ART nl li -EMI,IE, wAf TMER! A AYTO- Y W,ry CASE fllFNIED TO MEpCAy
<br />11 NIEONANCY IN THE PAST 3 MpNTNST (Sr+ws;ly r« w Nq1 EkId11NER Ok [OFKINER
<br />rsn«;3y r« «Nq3
<br />A[CIOENT, fUICIPE. MO/M[IDE, UNOET, PATE 03 IN/URY (Mq., poF, r•.( fIDUR OP IN1uItr bESCRIRE MOW IN113RT OCCURRED
<br />W PINGING tt+rESTICrAT10N /3Pgt r1-/
<br />907. 90b. 90c. M 90d.
<br />R+UYRr wT,wQR1t -fACE O/ IN3YRr- M hgwq. /grlw, rNggr, IgsMry, LOCATION STRlET Dk l.F~O. Nq. CITY OR TD1MM STATE
<br />(Se«dy r« « Nq3 dlKq WIId;wR, Mr. (SpgeNyl
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