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Rev. t tls7 STA7'E OF Ti6BRASKA• DCPARTMSN'I' OP 1�EAlTH APfU HU�lAN SF,RViCES pWANC$ Aj+l'p 3[JPPORT
<br />2 0110 0 2 9 J ��.STA�S�,GS
<br />, CERTIFICATE OF DEATH
<br />1. �ECEbENT - NAME FIF157 MIUDLE LA51� 2. SE7f � 3. OATE pF DEqTH /Monrn. Oav. Year� J �� �
<br />Harald Han Voss Male November 13, 200q
<br />4. CI1Y ANO STA7E OF BIRTH /NnalM USA.. name cp�nNyJ 5a. AGE - Lqel Bidhday �NDEFI t vEAR UNpER 1 pAY 6. pA7E OF BIRTN �Mnnyr. pgv. YegrJ ���
<br />IVrs.l 5b. MOS. OAYS 5c. HOUiiS' MIN5
<br />Ga^and Island, Nebraska 87 � December 29, 1912
<br />. 7. SOGIAL SECURT�V NUMBER 9a. PLACE tlF OEATM �� ����� �
<br />■ 505-14-1424 HOSPITAL � Inpalient OTHER � NuremgHnme
<br />Bb FACIIITV • Neme /Hnol �nsnNHOn, qive sWeel and n�mberJ � ER Oulpatlenl T � Res�tlence .
<br />Wedgewoad Care Center ❑ °a^ ' ❑ a��rs������ __.. _.
<br />Bc. CI�Y T�WN OH LOGATIpN pp nEATM Bd. INSIDE CITV LIMITS Be. CqUNTV pF pEATM ��
<br />Grand Island Vee � No � x$Z1
<br />g� fiE5l0ENCE • STATE 9b. COUN7y 9c. CITV. TOWN DH LOGAT�ON 9d STqEET AN� NUMBpp �Inc�ud�nplb C O� 9� INSIqE GtTr L.i��� � 5
<br />Nebraska Ha].�. Grand Island 3112 E. Seedling MiJ.e �ea � N� ❑
<br />�0 RACE � Ie,g., Wh4e. Blach. Americm 1ndiAn 11, ANCESTA� le.�����r�n omsn, elc� 12. � MApn1Ep ❑ WIDOWED 13. NAME OF 5POUSE !h w�M. p�w mpklen n�me1
<br />e�c 1 iSr�er,ily) � ISPe��h) NEVER pIVORCE�
<br />G White American Catherine Bartenbach
<br />O tA�. U5VAL OCCUPAl10N /Grva kimsrN wdrt don� duprq mosr 1 �b NINO OF B1151NE531NO118TRV 16 EOUCA�ION ISpecily qnde campleled) �
<br />O o/workr Iile. pvenrlronreAl � en ry ond � 10-12) � Cdlege it.a n, 5-� -.........
<br />" S�ie�t Metal Worker Metal Fabrication ��t�i �rac�e
<br />� 1A. FATHEF.NAME . FIFST � MIpq�E lA$T t7. MQTHEH FIRST MIpqI.E MAIOENSURNqME �
<br />7
<br />°= �,mil �. Voss Christine Mahr
<br />O • 1B. WAS nECE.ASEb EVER IN U.S. ARMEU FORCES? i9a. INFqpMANt-NAME �
<br />`y Ivas, nY 11� y?v. qive war antl tleles ot�BBrvICBeI
<br />� �� �"'����--- Catherine Voss
<br />� 19ry INFORMANT MA1UN0 AppfiFS5 . ISTREET OR R.F,D� NO.. CITV OR TOWN. STATE. ZIP� ����
<br />K
<br />°' 3112 E. 5eedlin MiJ.e, Grand Island, Nebraska 688p1 �
<br />� TO EMBALMER • 316NATURE 6 LICENSE NO, 21e METHpD OF pI6POSITION 21b. pAYE 2tc CPMETERV pRCpEMA10Rv � NAME
<br />4a
<br />� Y7
<br />� Not Embalmed ❑a���a� �Removal Nov. 14, 2000 Central Ne. Cremat�.on S�rv,
<br />� _.
<br />�� 270 FVNERAL HOME • N�ME . ptd. CEMETERV OH CREMqTORV LOCA710N CITY�OR TpWN $TATE ,
<br />� � � Crematbn ❑ 0��0,,0� Gibbon, Nebraska
<br />Livin ston-Sandexmann F.H.
<br />1.1i1 �, � 2YB il1NERAL HDME AO�RES6 ISTRFE7 OR R.F.�. NO.. G7v OR TOWN. 57ATE.21P� f
<br />f] t
<br />�� 601 N. Webb Road, Grand I�land, Nebraska 68803-4050
<br />29. IMME�IATE CAU E IEN7Ep ONLV ONE C U5E PER LINE FOR IeI. (6�, AND �c�� � 1 Interval bsM1een aneni a��n ,!•� ���,
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<br />_ .��p; � � 7 i �� ' c,� 1r�11 c.�iz�z-�c.- � ��-�.. -- /V a� �? �. �.. � �� �/L.�.��-- ;''� � �,� � C'� � { t 1
<br />� LL OVE 7D. OR AS A CON OUENCE OF I Inlervat Eelween onsnl ann �+..,•� �
<br />I �
<br />C'7 161 ' �
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<br />Dl1E �(O. OR AS A CONSEOUENCE OF� I interval benvsen onse� ann n•�.n� �
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<br />pTHER SIGNIFICANT CONOITIONS - COndllions cOnlributing 101hE APnlh Md npt rgIa10O PART 1111F FEMALE. WAS THERE A 2a AVTOPSY 25. WAS CASE fiEFEPRE(] TO AIEbICA�
<br />PART PRE(iNANCY IN THE PAST � MONTHQ? �- EXAMIN�R OH COFIONF �
<br />IApBe 10•SA) ��s NO VM Nv Viy No
<br />26e. , 28b. pATE OF INJURY �Mo„ OYy. YCJ 26c, HOUR OF IN.IIIRV 20d. �E$CHIBE HqW INJURV pCCl1RRED � T
<br />� Fccidenl � llndele�mined
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<br />�$urc�de � Pendinp 26e. iNJURV AT WqRK 281. PLACE (�F�JURY ; M�pm@, lerm, a�renl. InGOry 28A. LOCAYION
<br />❑ ❑ ❑ OM'ce bu� di 91r.. S nyJ
<br />Hamic�de Invesi�ga��an Ve9 No
<br />27a UATE OF dEAiH (Ma.. OTy. Vc� � � 28e. �ATE $16NED (�.. Oay Vr.l 26b TIME OF DEATH
<br />�� � If ��/�� S �
<br />�� 276. DATE SIONEU �Mo.. Dny. YN 27c TIME OF pEA7H � t 28c. PpONOUNCED �EAO /Mo. Osy, Y�J 2Bd. PRONOUNCED D�AD /Nn���
<br />� � � � �j'��a� '� ' �L� n'� "" � �� ,
<br />� 27d Tp Ine dBe1 a1 my knpwlBd eeth acr.�rrntl a1 In9lime, d���111e an � o � 2Be. On Ily 40iie W exAmm��ipn anA �a inv9g11pa11pn, in my pqni�n denih McW ad n
<br />ua0151918kd. ���:�� ./.��� , b me nme, dals �nd Wace eM due m M+s cewelal e��ted. �
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<br />S pnlre end TMa ► �� 81 naluro snd Tllk
<br />29. A10 70yACGb 115E CONTRI UTE Tp THE pEA7H9 30,8 Hp3 OFlOAN qR TISSt1E pONAT1pN BE CON91pERpp? 30.b WAS CONSENT 6RAN7ED�
<br />� � YES ND � UNKNOWN � � V�5 NO � YES 1\A NO
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<br />31. N�A , APDpES5 F CER7�FIEp (PHVSICIAN, COLiONEF�S PHYSICIAN tlP COVNTY ATTORNEYI /Type pr Pnnf ,
<br />� � � �� . c� 11 c U-=� , .� � C'+� � � �: �. � u "-�c: � (�) � ('� 6
<br />32a. FE0137RAR � 02G. bATE FILE� 9Y EatSTNAp IMa. Onv Yr.l
<br />$THEE7 qq R.F.p, NO. CITY Dfl TOWN 5iATF
<br />FOR VITAL STATISTICS USE ONLY
<br />Place .......................?�.,.....,........................B................................C...........,.........,......,...D........,.,......,......,...,..,�........,..,......,......,......Part II................,,..,,TMV...........................
<br />NSC ...................................................................................:.................................. ..........Census Tract Na.
<br />Wo r k ..........................................................................................................................................................................................................................................................................................
<br />UC ..........................................................................................................................................................................................................................................................
<br />. Reject ......::..:.......................
<br />............. :..................................................................................................................................................................................................
<br />rPrtif this to be a true and correct copy�o�t�ie origirial`'
<br />I hereby , , y
<br />filed wii!� ,`�r- `�L?�a of lebraska
<br />��.,�,�-.___ by �
<br />S; �.;�.e ��; � �,;; �resen� `' .�-- u�y of ..� ��t a�u��a� Mora�r-s�r� w+�c�,s�
<br />r�a►� �, �,�
<br />� Notary PubliC My � �
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