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STATE OF NEBRASKA
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<br />WHEN THI$ COPY CARRIES THE RAISED SEAL pF THE NEBRASKA DEPARTMENT OF HEALTH�.�'#D �'IbNh4N TT CERT7FIE5
<br />Th7� BEL�W TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASIFX DEP,�IR�TME/uT bF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPpSITORY FpR ��T,AC�RE.COR��., ` +
<br />� ,�. \ I� �� � Y
<br />DATE OF ISSUANCE �
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<br />�LT �. $ 2D11� �s�s� N `tcop p�a� ���ie ;�
<br />2 o i o o� s 1� o��T,����'� �pN� ;.
<br />LIlVCOLN, NEBRASKA HI.IMAIV'SERt�'IC'E5 , `
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<br />STATEOFNE T' ° �
<br />CERTIFICAT� OF DEATH 7 � ��...,�_3
<br />r I. PECE�ENT'$.NAME (FIr61, MIOdI�, LASI, SW11Q ��, SEX 7.O�iEOF�EATH (Mo. qdy Yf) �
<br />❑VE9 ONtl
<br />Y21.LOCATIONOFIHJURY-5TREETBNUMBER.APCNp. CRY/fONT!
<br />ig Female June 14. 2007
<br />5�. �GE•u�I 81�lhda� 50. UNDER 1 YEAR 6c. 11N�ER 1 p�V 6. DATE OF 61pTH IMo., Day. Yr.)
<br />(Yre.l 79 MOS. DAYS r+ouAs �+�NS. June 10, 1928
<br />0�, PLACE tlF �EATH .
<br />_. _.___... __�_-�. CGSL1I6t: .- ��C��EEg_'�vu`
<br />�f�OfpiG�i�lllfy ^
<br />a !b. FACII,ITY•NAME (11 nol In�tilulion, gir� nreel rnd.numCU)
<br />O ❑ ER/putp�p�nl Q De[edenl9Noms
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<br />a Gelden I.iving Center. Park Place ❑� oom«�suK�roi
<br />� AaCI7vORTOWNOFOEATH �InclupyZlpCOdi) Bd.COUNTyOFDEATM �
<br />W Grand Island 68$03 RaZI
<br />�j AG.RESIOENCE•STATE o6.Cpl1H[Y gp.LITVORTOWN
<br />a Nebraska Hall Grand Island, Nehraska
<br />� 9d.8TREEfANDNUMBER ge.APT.NO 91.i1P[ooE 9q.INSiDECiTYLiMiTS
<br />} zzia Ma�leWOOa P�.��� baao� x, rEg o�o
<br />$ 101. MARITAlBTAip$ ATTIME OF DEATM �Mihl4d q H�w� �+u�aa 10C� N�MEQF SPOUSE (First, MiORI�. La�[, 5�11i�) II.i4, Qiv� maid�n n�m�.
<br />E OMard�d,Cui�evaraiad Omdow�d �ui��.a ❑untinown Roberk W. King
<br />0
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<br />11. FATHER'5•HAME (Fir�t, Mlddl�, La�1, Sulll�) 1$. YO7HER'9•NAMH (Firtl. M�ddl�. M�iA�� 54rnimll
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<br />r Frank Waskowiak Anna Galus
<br />19. EVFA IN U.S. ARME� PpRCE$T GN! dal�s 01 s�rviC� il ylf. 1Y. INFqRMANT•NAME I4O. RElATI0N5NIP TO �ELE DENT
<br />(YO.,no,orynN.) No Rohert W. King Husband '
<br />tS. METND� OFOISPtl&I710N IBa.E1AB�LMER•SIGNA7URE 16b. UCEN5E N0. 18c. �ATE (NO., q�y. Yc �
<br />ve���i G1oo�auo� Not Embalmed .Tune 15 � 2007
<br />IACrcmetlon OEntombm�nt �6d.CEMET�RY.CREMATORY0A0THEqLOCATION CITY/TOWN STATE
<br />❑A.m�,.� ❑o�no��s�.�;�r� Westlawn Memorial Park Crematory Grand Tsland, NE
<br />th Fl1NERALHOME NAME ANC MAILING A�ORfi55 (5trael, CUy orTown, 54�d 170. Zf0 Cada
<br />Apfel Funeral Home� 1123 �;Pat S�cond, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH (5ea natructions and exemp ea)
<br />19. PARTI.fMRtn ' APPRD7(IMATEINTERVAL
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<br />IMME�IATE CAUSE: � tlnspl lo deeth
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<br />161ME�47E CAUeE IFlMI ��) vr •� G 0� �� Gt+ 7 � S� � p 1"L.� ���R.K� �C'�� � V�
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<br />18•PARTII.OTMERSIGNIFICANSC NtlIT10NS•COnCi110na[onlrlh�linglolh�plBlh6u1n011'elulllnpinlMUnd�r/yinpuua�flivtninPART1, 19.WASME�ICALlXAM1NER
<br />C D � �, ���N�-�* VC9.� ����'I 1 �J,S pqCpllpNERCONTACTEO'!
<br />❑ YES NO
<br />w Sp,IFFEMALE: p1 .M NEROFOEAT�{ 71b.IFTRAN$PORTATIONINJ�RY 2�C,W�SAN�UTOPSYPERFORMEO?
<br />� �Noi o�aqn�n� within pu� year �aturol 0 Homldd� � DnrplOp�rnor
<br />❑ praqnant a1 �imr ol deaih ❑ Accid�nl�J pendlnq Inr�p�gaHpn
<br />❑Peseenper O YES �NO
<br />❑ NvI pnpneN, b�t piegn�nl within �2 d�y� 01 pulh � P � Q° ���� 71d WEFIEAUT'pP$Y FWDING9 AVAI�ABLE T0
<br />� ❑ 5ulck� � Cpu1a nol n� dele/minad
<br />° 0 Nmprcpnenl,hmpregnml�9dayetolywrbelondeem � � C70therySpeClry) �p�7ECAUSEOFpFaTM?
<br />� C] Ilnknown�IprapnamwlthlnmppostyeYr . [) YES �NO
<br />�,�j Y2�. �A7E OP INJURV (Mo, �ay.yi.) Y2b. 11ME tlF INJtlR`I ,�2C. PLACE OF INJqRY•A[hom�,li1'fn, iVOOI, hclory, aflic�builtllllq, COPlINClion fiU, dC.ISp�tl�y)
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<br />� YYd.INJl1RY ATWpRK7 77�.OESCRIBE HOW INJURY OCCURHEU
<br />Virginia Marie
<br />I. CiTY AND STATE OH TEqRItORY, Oii FOREiGN CDUNTRY OF BiRTH
<br />Loup City, Nebraska
<br />7.SOCIAI.5EGURfTYNUMBER �
<br />_. ST�iC . .. IIpCODE
<br />�3�.OATE / tlfoEATH(Mo.,D�y,Yr.) x 2/a.0ATE5iGNEG�Mo.,Day,Y�.) ��b.TIMEOF�E�Tn
<br />s �s � � � � G $` m
<br />+, �96. 7Jc.TIMEOF�EATM $� 2�C,pRONOl1NCE0DEA0(Mn.,Gay,Yc) 2<dTIMEPRONquNGE00EA0
<br />��_ (�• ��. - 7;z3 � m ��K� m
<br />s� aae, To tna desi ol my xnwi�ap�, d�a�h ocenrred p� m� clm�, d�u and yau ���� 24a On �he basl� ol nammanen andler Imeruysiqn, In my opinian eu[h oeourred ei
<br />�� d tlu� s c� i�1ed ($iqn�l�n �nE TIIIe 1 � m� nm�, dnr and plu� �ntl du� lo Ma ea��s(�) m1�d, (SiqnaN�� �np TIU� �•
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<br />SS.D��T00ACCCU$GCONTRIBU�ETpTHEOEATN? Y6N.HASOR6ANORTI$SUEDONA71pN6EENCON$IpfiR6D7 I 76�,WASCQNSENTGRANTE�1 � � �
<br />�' ❑ 1'E5 ❑ NO PROBA9LY [] IINKNOWN Q YES NO NolApplic�61�i17871f kd Q YE5 ❑ NO
<br />27 .NeME,TITLEANOADDRESStlFCERiIFIEA{PMYSICIAN.CORONEq'SPHr51CI�NORCpUN �TTOqNEY)(7yp�a�P�int1 �� ��� �� �� � �
<br />Donald Wirth M.D. 2116 W. Faiclley ,Ave.. Grand Island, NE. fi$$03
<br />Pea. REG�STRAR'9 4iGNAT1IFE 28p. AATfi FiLED BY REGIS7RAR (1AO., D�Y. Yr.>
<br />_ ��G(!�� ,(�. JUN 2 4 2007
<br />WHS•61 11/03 (58081)
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