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<br />Lats Eleven (11) and Twelve (12), Hayman's Subdivision of the West Half of he Northw�t +� N �
<br />Quarter (W1/2NW1/4) of Section Twenty Five (25), Township Eleven (11) North, Range fien �
<br />(10), West of the 6 P.M., Hall County, Nebraska.
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBR.ASKA STATE
<br />DEPARTMENT OF H�ALTH, IT CERTIFIES THE BELOW TO B� A TRUE COPY
<br />OF AN ORTGINAL RECORD ON FZLE WITH THE STATE DEPARTM�T pF HEALTH �`, J�
<br />BUREAU OF VITAL SmATISTTCS, WHICR IS THE LEGAL D�P05IT�$Y._�DR
<br />VITAL RECORDS. _= --- = -=--
<br />DATE OF ISSUANCE �- _
<br />s , - ��� _
<br />AU6 �119�3 20ii00�s� � :: -_� =- __ . - ---=
<br />STANLEY S�..CO(3��r '��TO�'
<br />LINCOI,N, NEBItASKA SUR�AU 0� �1��L`�-£��'�T�T7��=� -
<br />""- -- - - - -- - - .
<br />- -- - ,;�_� --
<br />STATE OF NEBRASKA - DEPAR7NAENT OF HEALTH
<br />BUREAU 0* VCCAL 5TAT1$71CS , ,
<br />CER7IFICATE OF DFATH
<br />1. �ECEDENT • NAME FIR$T MIODLE LAST 2, SCX I�7. �ATE OF �EATF1 IMpnth. Opy. Ywr)
<br />W1LI1dIT1 W11t8� i .d�.E
<br />4. C11Y ANO 6TATE OF &fTTM (M nOf in U.S.A., nYm! FOUndyl `� AaE '���N 6. �A E OF &RTH /MpnM. Oiy. Y�arJ
<br />(Vri.l 5b. MOS. I OAYS 5c. MWiiS AMNS.
<br />c���oii, �ve��a$x� ss � � ; o�tor�r a, 1934
<br />7. 80CIAL SECUAITV HUMBER Ba PLACE OF �EA7W
<br />FIO5PITAL: x7 tnv:nem � ❑ Ep/ONpetlaM ❑ DOA �
<br />508-38-4237 � 07HER: ❑ Nuninq Hom� � Reeidsnte ❑ p�Mr/Sprciryl
<br />� Bb. FqCILITY - Nema !tl nd inatmrtion, yiw sh'eer and numbr�J BC. C�TY, TOWN OR LOCATION OF DEAtH BA. �HSIOE CITY LIMITS 8!. COVN7V OF �EATM
<br />( M yen a nbl
<br />' St. Francis Medical Center Grand Tsland, NE es Hall
<br />9a. RESIDENCE - S7ATE 96. COUNTY DC. CIN. TOWN pR LOCATION 9d. STf1EET ANO NUM�Efi (IncluClp Zq COWI 9e. INSIDE CITy LIMITS
<br />�$PICMy Y!d Or Nn)
<br />Nebraska Hall Grand Island 2419 So. North R�ad No
<br />10. RACE • ��.g„ White, &sck Am�rICM� Indi�n, 11. ANCESTRY �s.q..11alian. IMxiCM, 6amen, e1CJ 12. AAARRIED,NEVER MARN�ED, 13. NAME OF SPOUSE (M wNS. plw maidsn n�)
<br />etc.l lSpeclNl (SPecIA') WI�OWED, DIVORCED ISpscNy)
<br />White Welsh �� Married Max'orie A. Do�[nan
<br />t1e. USUAL OCCUPATION (G7rs klnd d wpk dnn� dulinp mp� 140, K1N0 OF BUSINESS INUUSTi1V
<br />d workin91i7s� swnYropndl �a� E7�mMA�7 a S�COndary 10.72) I Calkqa It-4 w 5•� �
<br />President, Landhandlers Inc. Excavatin Land ��°� 12 '
<br />16. FATHEFl - NAME FIRBT MI�DLE LA$T 17. MpTHER • MAIDEN NAME FIRST MIpDLE LAST
<br />Edwal - Roberts Nina -- Wi].tse
<br />18. WA5 OECEASED EVER IN U.S. ARAAEO FOfiCE57 19. INFpRMANT - NAME - MAILING hD�RE55 �STREET OR R.F.O. NO., CITV OR TpWYa67A��1P1o�
<br />1�ee, rq, or unk.) �M ye6, qfVe wu �nd dabe af 6srvice�) LVL� 8a
<br />Yes National Guard 1952-1958 Mar�orie Raberts, 2419 So. North Raad� Grand Island
<br />2D9. 9URIAL, CnmaMn,RemovN, Z06. OATE 20c. CEMfTEq� OR CREMATpRY • NAM� 20d. LOCATION CITY Oi7 TOWN STATE
<br />Donation
<br />'al Au ust 27, 1993 Westl,awn M�moria7. Park G�'and Island, Nebraska
<br />27. EMB MER • SIGNATUAE a LICQdSE N0� CL S Q 72 FUNflRAL F10ME • NAME ANO AADRE$& ISTREET OR fi.FD. NO., CRY OR TOWN, STATE, ZIP��p po�
<br />r ,� OG7
<br />A fel-Butler-Geddes, 1123 W 2nd S. Grand Is NE
<br />1MME CAU E �ENTER ONLY ONE CAl15E PER LINE FOF �y, �6�, ANU (CII , I Imerval 6etw�an oneBlBne Csalh
<br />PART �
<br />� Respiratory failure '
<br />DUE TO, OR AS A CONSEOUENCE OF: I Interval psiwesn pnepl and d�Nh
<br />diffuse metastatic adenocarcinoma, primary site undetiermined. ;
<br />DUE 70. OR AS A CONSEIXIENCE OF: � I Inlrrv�l 6alwesn onsM and Ceam
<br />1
<br />I
<br />OTHER 51GNIFICANT C�NDITIONS - Condition6 CAntributirp to Assih but not ralatad VART 111 IF FEMALE, WAS THEFE A 21. AUTOPSY 25. WAS CASE REFERRED TO MEpICAL
<br />PART PREONANCY IN THE PABT 3 MpNTH5? dy Yea a No/ EXAMINER OR CpRONER9
<br />�� � Isprciry ran a nb1 �
<br />ve� ❑ no 0
<br />ZBa. ACCIDENT, SUIC1pE, Y1pMIC14E 11N�ET., 28b. �ATE OF INJURY (MD.,Day, VcJ 28C. HQUR 6i INJURV 2Btl. OESCRIBE HOW INJURV OCCURRED
<br />OR PENOING INVE8T1(iAT10N (SplCIIjr1
<br />28e. INJl1RY AT WORK 2M. PU10E OF INJURY - M Iwme, Iprm, eva�t faclary, 28p. LOCATION STqEE7 OF1 R.FD. NO, CITV OR TOWN STATE
<br />lSpecily Ysa w Nol alfica Duiidirp, arc. lSVec�lY)
<br />27p. pA7E OF UEATH �Mo., O�y. YcJ 28�. DA7E S16NED �Mn., Ory, Yc1 286. 71ME OF DEATH
<br />24 August 1993
<br />��� - �
<br />27n. DATE SIGNE� lMO.. Opy, Yc) 27C. TIME OF �EA7M $��� �C. PRONOUNCED DEAD /MO.. Uey. Yr.1 2Bd. PRONOUNCEO pEAO (MOUq
<br />� �� �
<br />� 25 August 199 8:21 p 8'"
<br />�� 27d. TO the 6n1 d my a0pe cur t timv, d�ta an �M dus 1n 11�� r�� �. 0^ 1M b�sis d axaminrtwn �nC/p invaenpa6an. in my opnion tleMh occurr9C et
<br />c�ubala) Wtld. b � a�. tlete 9M pl�cs and dw ta IM Ceusel6l 6lated.
<br />Si ngWre and Tipa ► �� � S� �Wro �M Titb
<br />29a. �ID Tp6ACC0 u5E GONTq19 T E D w F1AS OR6AN OR TISSM1IE UONATION BEEN CO ERE09 306. WAS CON3ENT aRANTEp?
<br />❑ YES ❑ NO UNKNOWN ❑ YES NO ❑ �ES �
<br />31. NAME AND ADDRESS OF PTIFIER �PHYSICAN, CORONER'S PHYBICAN OR CbUNTV ATTpRNfV� (Type w Prmt�
<br />Dr. Wil am ,7. La on .D. 2444 Faidle , Grand Island, NE 6$803
<br />32s. RE(315YRAR. 32b. DATE FILE BQ Y R�415TF O IMa.. �sY. Yi,)
<br />.-._.� 3 �93
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