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<br />Lorraine
<br />AND STATE OF BIRTH rp IId h !
<br />Wolbach, Nebra
<br />KYAL GURITV NUMBER
<br />508-28-3433
<br />Aram - Nanla nrnar:ww
<br />nurla caurwYl 5a. ADE - LaM BkaKMy
<br />IYn.I Sb. MOS. DAYS Se.
<br />~ 62
<br />aa. PLACEE OF DEATH ~WT~' Q ~ Q ER/pulp•Mrk ^ DQA
<br />` S T1JlE9; ^ Nir~lnp Hann C~ HMidarw O Otlw f>A'rc;~Yl
<br />hr awal and nunllwJ !c. CITY, TOWN OR LOCATION OF DEATH
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<br />IMnAty Yrs
<br /> 10. RACE - N•4. W6r. B4cY. Amariean YIpIY1, i~. ANCESTRY (ag,IWlan. MrMICan, Oarnlan, a1e:.1 ~2. MARRIED,NEVER MARRIED.
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<br />s 18. NAME P
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<br />White American 0 ~ wtaowEb, DnpaGEn rsweall~
<br /> ,+~ USUAL OCCUPATION rcrw a+d d work aan. c`,..w Inod , ad. KING OF euawE8$ aabu$TRr
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<br />1 E a eaealtaary ~•~ ~
<br /> Clerk a V
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<br /> I$. FATHER - IIAAAE FIRST MIDDLE LAST 17. MOT -MAIDEN NAME FIRST Mlpbl,l
<br /> Edward
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<br /> 19. WAS DECEASED EVER M U.S. AINAEG FORGES?
<br />rv«. na, a u~k) to r••. ~ wai ane data d wrlc.q 79. INFORMANT -NAME - MA1LNiF1 AODRE$$ (STREET OR R.FD. .. CITY 1
<br /> NE 68801
<br /> NO
<br /> pa. BUIMAL CrMrMFOn.iWnfWN. '106. DATE
<br />DdIaliOn 20e. CEMETERY OR CREMATORY yNAME pet. LOCATION CR
<br /> Burial June 17, 1991 Westlawn Memorial Park Grand Islam
<br /> ?t. T NO. ~ 22. FUNERAL HOME -NAME AND ADDRESS ISTREEw OR R.F.D
<br /> fel-Butler-Geddes, 1123 W. 2nd Grad.
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<br />' Cardi es irata Failu e
<br />DUE TO, OR AS E OF- I ~~ 6aarpi awyl
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<br />None
<br />r. ACC1p67/T, SlNGOE, HOMKdOE. UNDET., 20b. DATE OF MLIURY INb..O'sY, Y•.1
<br />OR PENDMK; NJVESTKiATION /Spdyl
<br />f•. IN.AIRY AT WQRK tat. PLACE OF INJURY - N tIpRM, pren, aMaa[ bbblY.
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<br />PART Nt i FEMALE, WA$ TFIERE A ~. AUTOPfY 25 IAlI1S GI
<br />PREfiNANCY IN THE PAST 7 MONTFIS2 rBMd,' VM d Aigt
<br />Yaa ^ Nei
<br />OF tNJURV 2$d. DE$CRIaE MOW IILIURY rrrJmcn '
<br />CrtY
<br />___. ~-..~ ~. ~.^-... , .. ,. ~ R04 DATE $IGNE7 eM0.. D4% W.l 89b. TMI
<br />1~ 9 ~
<br />27D. DATE 81OIIED /Ma, Day. Yr.l 27c. TIME nF DEATH ~ lac. PRONOIAVCED pEAp Aar., tlh,. Yr./ 89d 1M11
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<br />27e. To aer 6rt d my . ar9r r ena 9nra, and dw b an 7M. On 91a Err q aeranrinarnn .-• •;, +~'I,~rYMriw r n9
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<br />and rata - s1 and 71aa
<br />pq TOBACCtl USE Ttl THE DEATH? HAS ORGAN OR T1Pe;;[ uONATION aEEN CONSIDERED? 30b. WA$ C4116B~IT~<iRAN1
<br />© YE$ Np .~ lM1KtVOWN OYES }~7 NO L3 YE$
<br />MME AHD ADOi1E$$ OF CERTIFIER IPHY8ICAN. CORCNl~A S PHVSICAN OR COUNTY ATTORNEVt IrYP~ or PrMry "'
<br />Dr. Gordon D. Francis `721 West Sevent}~ Grand Island, Nebraska 68$01
<br />RE01$TRAR , 326. DATE FILED $Y AEOI$TRM A
<br />•~'. __.._.. JUN S _41
<br />STATE OF NEBRASKA
<br />WMEN THIS COPY CARRrES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF (-IF.q~~H AND
<br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORI47NAL• ~ Cbtrt'p+ ON
<br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES;~/I~~~:~`F~~'~)L~r
<br />OFFICE, WHICM rS THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~ ~,~ .. ~ ~ ~.. • • ~ , a
<br />DATE OF ISSUANCE
<br />ry ~. ba"
<br />IV1AY 2 4.2010 ~ ~~Y OgPe~ -
<br />..,a ~r~~`~a , ~ ~~G~srRA~ ,~
<br />LINCOLN, NEBRASKA "' 010 0 3 7 S 3 ~'~~' ~~~~ ~~ `
<br />STATE OF NEBRASKA - OEPARTIAR~Kf OF HEALTH " ~` ;, ~ wl + 1 ~
<br />etllSrAU ~ VITAL STATISTICS Q ~``~ "~,': ~~~.
<br />ccw~n~cA~ of oEArH tl
<br />FIRST MIDDLE LASr 2. 9Ex ~ ` ~ ~a. DATE OF DEATH MAoltla. Qr. r..n
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