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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF `HtAL'T1d MD HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE PRIGF/1~I,gLt AECgRI` QN FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, AL CQ , I)S. , OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE I ally 0 2010 2 p 10 4 5 9 7 3 AT DFAI21AIT OF HEALTH" AND LINCOLN, NEBRASKA HUNP~IN 1Vx ~r STATR OF NEWASKA. E&ARTIdWr OF NMI 1 SBRVK AND 1 vr1.u 8r4 "D 3'06 2 CE1kW1CA'!'( OF b13ATH 1 NT- T SIX 9. DATE OF pay T9r/ sloold" " WNW Mels Navin r 18.2 1 4 CITY AND TA N AW O _i A. Aiw c&&*,r 1 UNDE t •N' 'Iellog Mobile. AM ama rvn i w a tk. Jark y 21 r "IS 7' SOCL4L SECLIRTIV R - 416-12-1677 ! TEL 60 ken" orc1~R ❑ N..TE..n. Sb FACIL No to nAaxwA~F'al pLy AtANPI FIeN 1 ❑ FA OIApE11Yr. ❑ hwba ICr . . GOOd80epM fth HgOPW ❑ DOA ❑ OP1u A9wrN: 'AF CITY TOWNORL6C1',31., OEA m Ae COIJMY a. KNWn", ftT7 YM No I 9e, RESIDENCE - STATE 9D TY SC. CITY. TOWN OR LOCATION. b STIIFE'T AND glnyr i CYrb ge p7v lrBT3 Nebraeke HaN Llrand wow 1518 Ha2pe ow Ywe R] ~ ❑ 10. RACE - la.q. VAW. lWw+ Awrwcrl►1dr11. ES b g eeLew. AINFY; finl.AFC Mtl 1 _ WIDUAMD, 19 ft" OF SPOUT E A14 rtAr. ipiiYFn wF.rN Vwft Ae 1 IsoecMl (SPFCArI J~- M _111EFJIC~ _ _ -f1 R DNORCFD A '148. U5UALOCCOPATCh ICP AApa/ArrAdutl &ft1nWf ib KINDOF9USMSSWDOSTRV ti ,lupomw d apA.g AY. IP7n / easy ee IAARI#n U.S. PO*"W Siam" 191 i14a•5.1 'te FATNER-NAME FIRST NIODLE LAST 17 M11THEP Mkiteel V. O'Rourke Mw 471eG wAm 18 wAS.DFCEASEO EVER N U S. AFNED FORCE T -n392 1t6rt . NA . (r cY~ M uPkl IE yes. aw. wn 11 tNV!PAEI . 1125/48 AudW OPtibUde 196 NFORM/WT LLAA. ADDRESS 1ST ORRFO NO.CrIYORTOWN STATE-Z" 1518 H"p Grand lekind, Nebraska 88801. 20 E TORE A LICENSE NO. 21 A. -T11ODOF *SF VT*`t 216 DATI f 2tc OR $OFw M- EI RFnm NW 20.2M (3MW NOW 061Cgowl" Zbo AAIE Pttl l 696 OR CRE#AA ORV LOCATION - CITY TpWN 6vM>t8 w4andermann Funeral Home ❑ Q.PIFLOP ❑ OmwP Grand ldWid. Na6nllik* NN~g 2Ye FUREgµ mow ADDRESS MEET DR R .D. NO., cITT OR TOWN STATE. 21P1 801 N.. Webb Rd Grand Island, Nebraska 88803 23 PARE 11MSONT 'ENTER ONLY ONE C PER 1,0111 FOR I»/166 AND lep L,y1 y OUE TO. 06 AS A CONSEQUENCE pF hhh~I~~ DUE TO.OR AE A,;ONSEOUE E - . i/sM.wl llelyswArwilt rehWr kl ~ PMT OTNEp "W I CA PIT CONWTIONB - CvkMidg c~~FAwAlrq q qIF GwM-~e1A z w ~PPMT / F F THEWAS THERE A N AUTOPSY No a wAT: e PREGNANCY IN PAST MONTN87 EIIAALeYEg OR CARDIWM (ApAs 10.541 TO w Yp Yea w 3AA w DATE OF FIURV IAb. Day. I¢1 28c NQIIR OF IN.1Ugr Rd. DESCRIBE NDW W000RV OCCUFFIM ❑ ACCOpM ❑ UdMW.n..yP plAEpF~y M ❑ Suatla ❑ Pe1w41 Zee NAIRT AT IMOIPI 2eI a111i.•eDhIMd51A-ik .~Y tW- Vw hC" 7e0. LOCATION STREET OR RFO NO CRVON T000%, 1150,, ❑ rrm.c+er tir~Ugalm TM ❑ np ❑ Mc 2Te DATE OF DEATH w 5-w Y.1 2% DATE SIOAED rAb DA. n r OF DtSAhr November 16, 2004 27b DATE S1t)NE0 PLN dy /rl T7c THE OF DEATH ~ sec PRONDLNCEO UEAC nN6 Gy, wl ye ~ DEAD Mr.• -~A vV 2 1, o'f • 3: 15- 21 h a AN 27tl To w 4wM a mN hnPwhPOe 0rrP1 «L1.1ay a ft else. ewe NItl dlw q FN 2BE. On Yr AeFiF d eFAnulsAn AAC r tawNn wsetl. ~ ■1e MN. dl17 ntl 11enw aed dw a errYl~~ awF..ec..wlp ~ T 4y_ r 29 DID TOBACCO USE CONT"M TD THE C,,ATN7 A NAS ORDANL OR TISSIW DON.:ION SEEN D+ See WAS C)NAprt OtAANTEp7 YES ® NG utAINO ❑ YES ® ND E] rE5 31 NANE ANA] ADDRESS QF CE TER IPWYSICIAN, OO1IpNE OR COUNTY ATTORNEri : r;WR ft- _ AL7 E.A- Sed*. M.D. 3219 Cenb* Avernus Sidle 103 Keam",Nnih - a, 68847 72e gECIN{TRAR Sle wTE 1Rlpp 9r Aw "t DEC =120