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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIE5 THE RAISED SEAL OF THE IVEBRASKA DEPARTMENT OF (�FAL-thi 4,At� �-1�1�1f� •, ERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH TH� NEgl3ASlC4? �RJ�1R�J�dV� �F�' HEALTH AND
<br />HUMAN $ERVICES, VITAL RECORDS OFFICE, WHICH IS 7HE LEGAL DEPOSITORY FO� �iTi���CC�I�D��-S L � 0�,
<br />�' ^� � 3
<br />DATE OF ISStIANC� � � � , 4� : ' _ p. ,'����� �1� -- - :
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<br />LINCOLN, NEBRASKA
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<br />37ATEOF NEBRASKA— DEPAHTMENT OF HFhiiTli AND HUtiAAN SER5110E$ FINA�1(SE� � � - , r'!
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<br />t. DECEDENT'8•NA6lE (FlreL � AAiddle. ' LesL S�t�;l
<br />Ste11a Peari � ideil
<br />4. CItY APID BTATE 6HTEppITOHY, OA FOHE1flH COUhFRY OF B1PTH 5g. ALiE•Lest Birthday Bh. UNDEA 1 YFAH
<br />(yrs,� ' MOS. DIiYB
<br />Weisaert, Nebragka 81
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<br />. SE%.?- �:. ;_,� -. .:3. MTEOF DEATH Ma. Day.Yr.l
<br />Female . ''- ' .Tuip 26, 2005
<br />8c. UNDEH 1 DAY 6. DATE OF BIHTH (Ma, Day. Yr.)
<br />MOUpB 6tIN6.
<br />June 30, 1924
<br />� 508-14-2977' t�e¢q�• n mveueM 4� m t�wnoHame�TC 'ar�sa�rc�
<br />86. FACI6ITY-NAME (1f nnt Insdtullon, qivg etreel antl numharj _ _ _�_ _ a� _n{��„�.�— .�
<br />Beverly Heal.thcare at Lakeview '
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<br />1405 Highway 34 We�t f
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<br />Anne K. Morae M.D.
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<br />9TATE
<br />Isl,and, Nebraska
<br />17p. Zip Code
<br />� 4$801
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<br />NOWN ❑ YE8 NO Not Apptleatde It 2Ba is NO Q YES ' NO
<br />+'ViN. COHONERS PHY810UW OH COUN7YATTOPNEYI (Typea P�nt)
<br />729 N. Custer, Grand ialand, NE: 68803
<br />EDBYAEG18TRAR (f0o.. D9}:Yr.}
<br />JU! � 9 2005
<br />NHS6111/03(6�1)
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