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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO B,E A TRUE COPY OF THE ORIGINq~;yR~CORD ON
<br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES,.'b'~'f/~4 RE'+Cw~1RDS
<br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~ ' ' ! 1 % '
<br />DATE OF ISSUANCE `, • ~~aNr
<br />.;;) .C~r
<br />S7}INLEY Q(„~PER
<br />ASSISTANT STATE`RE~~'T~YFt
<br />APR 1 4 ZO1p C1~PARE~I~' Q~ ALTf9 ;Qnr~r
<br />LINCOLN, NEBRASKA ~ O ~ O O ~ ~ ~ M~MAN' EFtb''I~'E~"a "''
<br />> ,'
<br />~ ~. '~
<br />-._ _
<br />STATL OF NEy1pA~1tA - >, ,
<br />CEPARI'MENT of MIEALTH ' • ! t g ..
<br />MNIICAU OF VRAL STATI$'IIC~ ~. '`
<br />~-~ of o~rnn~ ~~ ~ ~ `' q ~~ : ..~ ~ S 7
<br />1. DE ° T -NAME FIRST MNfOLE LAST 2. SEX 9. PATE OF OE/ITN fyfp~lwt ply, YMy ......
<br />Amos Boshart Jr. Male Novead~er 21, 1991
<br />4. CTrr ANb STATE OF lWTH /I rot b U SA, nn» cmnYyl Sa AOE - LMt Y {. BATE OF Mp1T1 IlAett4 q4; qry
<br />1 IYn.I Sb. MOS. ' PAVE 5e. ' MNIS.
<br />Wood River, Nebraska 60 December 11, 1430
<br />7. SOCIAL SE{x1RITV NUMBER G. FLACE OF DEATH
<br />3©~---3~F=3$1-1 ~- . ~? +.:. ~:~tualaw.M _ a Qw _ __
<br />- --. :...
<br />- -- _ - p711BR~ ~ Nyg1Yq Halm [7 RaNdN~EA Q OIMr (dpaelyl __'
<br />~ FACN.RY • NMtp AOf RI/IMNbIt. QA'1 lMra/ arai nlaltWd pc. .TOWN PR LOCATICMI OF 7R M. CITY M bEA~f ~ -- ....-:._ ..~
<br />St. Francis Medical Center Grand Island YNaA~
<br />es Hall
<br />M. -STATE 06. COUNTY YC. CTTY, TOWN OR LOCATION ptl. STREET AND RI/11BE71 A'lekafq ~ CatlYy y, pTY ~~ -.
<br />Nebraska Hall ~"°'y'""~A*I
<br />Wood River RR 3 Box 23b no
<br />ty. RACE - N.Y. Wplr, e4ck NnaAcan InpMt. 11. ANCESTRY laq.lpWw, Maaban, O«rllan, elc.i 12. MARRIEO,NEVEIi MARRIED, tS. NAME OF SPOUYE pl willt)NIrAlafKaq -
<br />rlc.) /BpacNy/ lSprJyl WIDOWED. DIVORCED (~/rNyJ ~~ ..-
<br />White German ~b Married Loret a 3. SC x
<br />+w. usuAL oocuPATION (aw kAd d an,r dm. dl.:p nba I+c. KMID OF eU&Hf:58 INDUSTtty
<br />W ItGtAY/lp AK awn N~MYbJ ~..--
<br />Farmer u~3 A riculture b~~ ~""" 8 °'''O°id"Y~,a ~ c.Ir..~n...s.~
<br />1!. FATFIER -NAME FIRST MIDDLE LABT 17. MOTHER .MAIDEN NAMF door ........ e . _ ...__
<br />Amos BO$~art
<br />WAS DECEA.SFO EVER Mi U-& ARIAEb FORCES? to NJI
<br />!Yr, % or utlk.l !X yaa, qiw war am cMr W auvlcaal
<br />no L~
<br />~ BURIAL, C~naYgn,RamdrY, 20b, DATE 20c. CEMETE'~
<br />DanNbn
<br />Burial November 2S 199 Me
<br />EMtlALMER - SXIAIA7U >< LICE/i9E NA. ~ /~ 2Z. FUNERALA
<br />A
<br />A~ TE CAUSE (ENTER ONLY ONE CAUSE PER
<br />tta Bo
<br />1 CREMATpRY
<br />onite
<br />E -NAME ANp
<br />e1 Fun
<br />lal, NI, AND Icl
<br />~'~~~-
<br />1 M~111d YAIr11Er1 aAM1 Md ~MM
<br />1
<br />1
<br />PART ~ • ~~ owarar...~r. ~ taw.u ~ tea - l:dndlayrla sarWAaAMp b tlaalYl ~ na telatatl PART M IP FEMALE, WAS THERE A 24.
<br />N PREGNANCY IN THE PAST 3 MONTHS?
<br />Yaa ^ No (~ ,
<br />ia. ACCpENT, BV HOMICIDE, UNDET., 260. DATE OF INJURY (Ak..Wy, Yr.J 26c. HOUR OF NiA1RY 26d DESCRIBE HOW INJIkiV O(
<br />OR PEAXXNfi INYESTIGATXXV (Z~cYy)
<br />la. INJl1RY A7 WORK 2b. PLACE OF MYJURY - Al Ibma, Nml, ,,Mr, ~btY, 2py. LOCATION STREET OR R.F.P.1
<br />l9PaCw!Y Yaa a IYVI dlno, Mfldirp, ab, fgP~+N1 ~
<br />1 wrwe..+rM..n,alr
<br />1 2S wAS CASE R~ To
<br />oaM7l EX111pE11O11O0IgN6T?
<br />ip+czXY rtie ArAyt
<br />November 21, 1991
<br />~ 270. DATE $VJNED /Ab.. Dlay. Yr,) 27c. TIME OF DEATH ~ 2!C PRONOl/NCEO DEAD (ll/p,. qy, Yi) ~, M10
<br />~ November 25, 1991 $:Q4 P.M. `~
<br />F
<br />27d. T'1 ~a a~ ~ ~w`~° ~~ ~. aw and prc~ rid dw b r. s zs~, on r~ brrs ~I ulrrwtwan rd+a hwwp~lon, XI my a
<br />b tN WM.1MM and pMp MM dlla b tIM crtuaalp arra
<br />and T ~ /~ ~r^
<br />and
<br />Zia. blb TOBACCO USE CON / TiIE DEATH? 30a. HAS ORGAN OR TI$$VE DONATKkI LEER CONSIDERED? 30b~ WAS CONSENT fiRANITED?
<br />OYES 116 tl UNKNOYVN ~ ~ ^ YES NO ~ ^ VES CI Mp
<br />31. NAME ANp ADDRESS R (PItYSICAN, CORONER'S PHYSICAN OR COUNTY ATTORNEY) (i)ya p pony
<br />.john Wagons MD $00 Alpha St., Grand Island, Nebraska 588U2
<br />aal~awtl at
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