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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEXIL~I-I`A~1PLJ. HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGI'~lA~ ~RE~bRI~.'bN FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVI~ES,•~I~ITAL•REC0~2~S• ~ . , .~- , OFFICE, WMICM IS THE LEGAL DEPOSITORY FOR VITAL RECDRDS. ~ `' ~ ~ " ~"`, w. , . DATE OF ISSUANCE ry ST,4NL~Y: ~O~R ~, ~F G~~~ ASSZS~i4lUTST~I~E^Rt~ISTi2AK LINCOLN, NEBRASKA 2 o i o o i s~ 3 NUM~IN'~Ek.V~~ES EALTHrXtAIl~J^,, .mil d~r~ ~ STATE OF MI~ItA~1E,A - dEMARTMENT 4F Ml`•AITH " 8. ~ ,' ~ 1 SIi11EAtl OF YIYAI STATISTICS ~~~ D ~~ C~'fiOrICAY'~ O~ D~llTM Y. D~EOfiIT . FIAIIE MiDDEE lA81 2. 9FX 9 DATE OF DEATH AMgntli Dtly Ig1Ay M 1 9:, ~• Atli A SIRTFi N nU9A.xpllF RYa>iyY SF -Call MIMIM tYEAR LN1DERtDAY 6, pJ1TE OF ~RTM pWlrlDb. I~Yi (Yr-.1 8p. MOS. GAYS Cairn, N~braaka I 1 ~ liG. MOIIRS' MMNS. Aril 12 19~b 5. SOGIML 11111ryER iF PIACE Qr DEATH - 5 0 7 -14 - 014 3 I.DSPITAL: 7® ~atlrrtl on+E~i: (~ Ra..,, l.a,. ` ADIElT1'•Nalatl (S AMwISiEIFL!'N'~yrltlAO AyPaM) ^ EIi OUPaaMtl _.- __~ RNgNlfa _ . $t.- ~`r~ltca Medical Center ^'10" Q'~ TY. TDM~1 !tl YIalO[ WITS CDIMY OEATiF Grand Island, Nebraska Y« ~ ~ ^ Hall itl • STATE 14 G0IN/TT 8c CITY. TpMF DR LOGA •}f. STREET AND N11M1lfi11 p~CIdYy21p CndAl !tl CqY LMffg Nebraska Howaxd Haelus 207.E H 58 b8~$20 v»^ w +aRACe•Mn-wFw. man n.ANCESTRrItlq.MTatlA-1FtldorLDnylwstltl 12.y~AMFNIED r-Iw1DOrrtD ,o.wwEaFSaroE s+~,r-al•+••r~w/.np ~8 ~.1 Whatte 11 German ,~, aYOF~ED Joyce Jena r+a usvAEDDpIPAT1oR ATtl~ovddadtlOp'ItlaWrgmcit lap It1NDDFe11yIfEt75tltOl:STFT/ a fDU CJ1TF0N l~arnlei r Dwn Fa]Cllt 14r~iy a~ e~arwry lo-~ai ca~pr n r a s•1 1 l 16 A HER-NAMfi F1~YiT MNDDE.E u8i y7 MOTIIEA Fi116T wlxE wMOER aunrMiE (dec) Fredrick Herr Harder (dec) Mar Behrin yL WAS DECGM9E0 EVER w D.5 ARMED FORCE$T yfN HFOrytlANT • NAME ryaa.na ar untJ nrs>i vl+war.mere.w+eti+c.H J der l>ab. L~FanaANr MAE.NFELADDRESS isTREET DR R.F o MK'j_ CITN DFI rDwN. STATE nR 2026 Hw 58 Boelus HH 68820 20. EMBAA.MER-8A3FUTUREii1CEF18E FA7. Q e Yea 1IETNDDOF p18l°GSlilpl.~ ~ ct6. DATE 21c, cEM1E161Y OR C1EWTnRr IWE O te 1C 1 ~~ ^~ { A~ . 199 ~andlslan~, City Cam. _ _ _. , ~ 22a FIDME - NAMSE ~CEMiE7~CRGAIATORY LDCATIDM Gtr OR i0YM1 .ATE Jacobsen Funeral Home ^`""'"°" ^°ovVOn 225. FlNIERIV.11pJl APPALSS ISTREET OR FLED ND,. ^.ITYOR M)Wy. gTAT$fiPl 471 "O" Street St. Pa 1 - ;ENTF,R GREY ONE CAUSE PER LINE FOR Ial.IC1. ARD Icll ~ aatl'W atlatlwa aAtln tlrn aMn PART Itll 1•}YI m el,a~e pUE T AS A C OF ~ y ~ p~yM ~N My Ly~ if /, ~ +.. 1 ~ ~ - J f~' bwam vltlK tlatl atlr'~ Icl _ ~ PART OTHER SICI~ICART CfklDligflg • Cantlarn cprwdruq tl aK nnn pt ~ neWne PAIiF Itl E FEMA(E. wAS TFE(E A a AUTOPSY 25 wA5 CASE REFFAFIEO TO 1~[x ~ - PREfyl1ARCY Ni THE PA57 3 Md1TNST M EXAMMNER DR OOROF~i+ yLgtltl 14Y' Yatl NO Yas ~Np Yatl ~ FY 2Ea 1!b DATE OF IMLAATy !!4+ Dtlr Y.1 7A~ 11p1p OF at/11F1Y 2!tl DE6CIi19E ROW w,WRY DccuwlED AKprq ~ ~~tlny.nrnail _ - M _ ^ Sw..dtl ~ P~prtq ~ ,21. Ihr~gt AT'Ar,~11( ~ 4-`AC[ t~F Mn~ - Ac 1~om~ Mnn yYeM ycgrY ~ pwv"4 5arc+Y) 2eq LOCATgFI STREET OR R.F 0. NO CITY Oq TOWM STAFF ^ ylnntlr» nr.~^ i Yw ~ IIO ^ ~ I --W~~ A 77a D TE GF EATM plb Qtl D y Y l l .~ r ?f/ GATE 8K3NED lib 1Ly v.l 2!b T11AE Cf pF.ATH ~tl ~ ~ y ~~ ~ y Q 7 l•/ar. E:I I 24 / .F.777 b ~ 1k %~ M _ _ 276 DATE llKiM6p A6 n T . v ~ 1 y : ~ ' r r ~, NA w , ~ p 1 DE A m 2 nr r•ypRp1A+CE0 LEAD IMn dy, Yr) 29a PRDNgI1NCEO OEAO Npw ~ ~ cc CC yy ~~ yy y y w ~ ~ ~y tl ~~ ~ :7 f 739 J ~L /7R') ~y I ~ rn ~ a )I . • Yom- ~ ~~---• M ~ r 27tl YO tlM Caal accw~tltl al yylrw sW Ara +u trM ~ ~ ~ ~ ~ On tlq Catlro d aramntltla' w ar rwtlebpMOn, w. mF spawn dtlnn Ocpnaa • CaatlMSl ~ ;; ~ Mumr. dlatl tlntl plp rq dr lO Yu c~welal tllaMQ artl T _ y~ l . -_ rd TM _.___ _..T .. . 3E CUM i0 > ~74~w,S di6sfL aR~ ~'IM,TIaM~ nEM _ ~O.p WAS CON8E~ D' j ~ ~~+ u vE4 __- YES .. ~ .... - Ryan A Crouch DD f 8Q0 Alpha St t~J.~~C.aYaMl Ielarlr] NB 688Q2p1b yq~ $711. RE I J~ 1 _ . ]20 GATE F1LE0lY RE(3y9 APEI ~ !d