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- STATE OF NEBRASKA
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<br />' WHEN TH1S COPY CARRIE5 rHE RAISED SEAL OF THE NEBRASKA DEPARi'MENT OF HFa4LTM Al� H#1MAN :SERVIC€S, I� CERTIFIE'S
<br />THE BELOW .TO B�' A TI2UE COPY OF THE ORl'GINAL RFCORb ON FILE WITH THE' NEBRASKA,�'PARTM�'11�7' O�' �i�ALTH AND
<br />HUMAIit SERVICES, VITAL RECaRDS OFF1'CE, WHICH IS THE LE�AL DEPQSITORY �DR VIT��`�?� ti ' tr. 1
<br />, ��..- . � . . .. . h" .Y�i fi / .
<br />�3ATE OF'ISSUANCE '
<br />.��. '� . � -
<br />� AUG 4 `� 20i1 5r�c�r�. �oo�ne�,�, : �., � `
<br />�, 011�0 6 4 9 4 ��sT��,������
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<br />LINCOLN, NEBRASKA � _ •: d-IE�M'AIV � q� �'° •
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<br />� 3TATEQFNEBRA9KA-DEPARTMEIVTOFHEALTHANDHUMAN&ERVICE&FlNANCEANDSUP ,a' ^.v' ,,,'
<br />CERTIFICATE OF DEATH . �Y� � °����a� ' '
<br />�'�1.DECE�ENT'8•NAIdE (Flrsl,. MltlEle, Laet, � 2.SEX � � 3.DATEOFDE�I1lYi�AAb;;.➢8�"�Yr:r� ,
<br />Hele� Irene Shi man Female Februar 29 2008
<br />4. C�TY ANG BTATE OR TEflHiTQ13Y, OH FOAEIQN COUNTI�Y OP BIflTH Ba. AQE•Leet 81rlhday 6b. UNDEH 1 YEAH 80. UNDER t 0AY 8. DATE 9F BIHTFi (6do:, Day, Yt.)
<br />' {rrs.) mos. unrs aouas ��as.
<br />� Alda Nebraska 94 � November 12, 1913 ,
<br />:. 7.BOOUELSECUHITYNUMBER - � �. - � - � �- 89.PLACEOFdEN}i . . . . . - . . . - .._.. . ._ _
<br />' 508-52- tl43ELTBL ❑Npanem �R f�Nwmn9HmaetL7C OHasp�aefedmy
<br />�� 8b. FACiLITY NAbIE (fl�not Inatitutlon, g(ve etreet gnd number) � ❑�p��penl � ❑ DeoedeM'eHome •
<br />Go1d Crest Retirement Center ❑ � ❑�cso�,n
<br />� Ba. CITX OR TOWN:OF DFATH (Inolude 2ip Codey �, pOUNTY 0F DEAtH
<br />0 RamoveJ ❑ oWer (9ae�Y1 ` -
<br />Grand Island Cemeter Grand Island Nebraska
<br />Y7aFUNERALH061ENAMEAPIDMAILINUADDRE88 (8lreat,CAymTown,6teteJ� � . � � � � � 7Tb.ZipCoEe�
<br />Apfel Funera1 Home 1123`�fsst`Second, Grand island, Nebraska 68801
<br />INSIDE CITY LIlERS
<br />da res D t�o
<br />1t. FATHER'8-NAIdE (Plret, AtlCdle, Laet, SuNUc) 12. b10THfR'&NAME (Flrst, Middle, Maiden Bumame)
<br />4di11iam Luth : Dora Nissen
<br />13.EVERINU.B.ARb1EDFORGE81GMedateaofpervtceqyes. 14a.INFOflNANTNAbtE � 14b.RELATI0N8HIPTOD�CEDENT
<br />�r�,�oo��wi Pta Larry Fenton Son
<br />18. METHOO QF D18P081710N 1Be.EMBALMER � 1eb. UCENBE N0. � 180. DATE (bto., Day, Yr. )
<br />X�Bu�� o�� ,,. " March 8, 20Q8
<br />OCremayp� ❑E�{anBment 18d.CEtdETERY,C RYOHOTHEflLOCATION CITYlTOWN BTATE
<br />MM V
<br />6aRE8�4ENCE-SCATE Bb.COtMtY �.G{IYDFiTOWN
<br />Nebraska Gage Adams
<br />Bd.STREET/WDNUMBER - . - . � . � _ .. . . . . . _.... . : BB.APT.NO � BI.DPCODE-.
<br />200 Levi Lane 68301
<br />10e.IdARITAL STAN9 ATTI6AE OF DEATH ❑ Mertied O Naver tdArtlad i�b. NA6AE OF BPOU6E (Flret, 6➢ddie: Lest. 8ufliz) It wNe, glvs malden name.
<br />0�art�d, tm seperered l�Ypio�ed I] niw�ced O unpw�m
<br />Adams 68301
<br />1B. PARTI.Enterihe � � Njurlee�woompqoaUo�-thatdUeWyoaus�llhedealh.DOMOTentarterminalevanlseuohasaardleaeReat� �� ARPROXUdATEINTERVAL �
<br />respireloryerteet,orvenhiai�erflM0la9onwNhoutahowingiheet6Uogp.pONOTABBREVIATEEnleranlyoneeaueeonapne.AddaddfUonelUnesHnaaeesary. � .
<br />UdMEDlATECAUB& � �88tI4deAUt
<br />@�dEDll1THQAUSE(Fh� . � � j ��1/yl�.� ?� � .. � i �
<br />��EQO�� WETO,ORASACONSE4ll6NCE0F: I onsettoQeaUi
<br />Indm�) �
<br />�Yqat�ne,� ro� �"r��l'�.G�'..C�., i
<br />enY�l�ingio6aaeueellated I
<br />��� 011ET0,0AASACON9EQUENCEOF: I or�aetwdesN-
<br />Emmtliell�BpLYINfiCAUBE ,�.�,,,-�yr �
<br />(d1�m4iJurym6tlnWelad (°l ,�,.]� ���� t
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<br />��°�^���) OU6TO,APASACONBEDUENCEOF. t areatiodeath
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<br />18. PART It.07HER 818NIFICANT CONDITION �CaedWane conldbuHn9 W the death batrot reeuHinB ����Iylny oause gHen le PART L .. 19. WA8Id80ICALEXAMINER. -.
<br />.��'t.I� j �e1'X►�� Ql.� CN-�� L� P ��-t?)'t/� C����i,tSB�!'�''�1 ORCORON@RCONTAOTHDI
<br />n Yff8 Np
<br />20.IRFEIdALE: �� - 21e. NEROFDEAiH � � 216.�FTRANBPORTA7fQNINJVpY 21aWA8ANAUTOPBYPERFORtdEp?
<br />'� Notpregnantx(thhiPaetYear �NetWal OHarnVdtle ❑DtivadOperelm ❑ YES �"NO
<br />❑ Prepnantattlmeoldeath ❑p��MOp�y,p��epg��, OPaeeangar
<br />❑ Not P+89nem4 6W PreAnenlruMbi 42 days ot dsath ❑ PeBeeUian 21d. WEREAUTOPBY FltJDIN08 AYALLABLETO
<br />❑8uldde OCOU�dnatbedetermHred ❑p�er(Spe�iry)
<br />❑ Nct pregneM, h�t pregnenlA3dayraM 1 yaer6etore death COMpLETECAU8E0FDEATH?
<br />� UpMrown 8 pregneN wNtdn pre pael yeer ❑.Y63 -� NO
<br />22a.OATE OF �NJURY (tdo., Day,Yi.) 22b. 77ME OF INJURY 220. PLACE OF INJUf1Y-pt home. term, etree6 tactory, otHna bulldNg, oonetruatlon eUe, ero. (Spe¢ity) -�
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<br />?Zd IIVJUHYrU'4YORK? ?2e. DE9CR�BE HOW INJURY OCCURRED
<br />❑ YE8 �NO . . ---- .'° � - - . '.. _
<br />22F.LOCATIONOFINJURY•STRE&TBNUA�BEH.AP1:Nb. CRYifOWN BDUE YIPCODE
<br />- 23a. DATE OF DEATH (b1o., Dey, Yr.)
<br />�� 236� @ 8 D o., Oay,Yr.�
<br />� � z3d. the m my knoq�edge .
<br />. �a�M tlrecaueeSe)
<br />rs.aoroaa use c
<br />O YE8 �NO PROBABLY
<br />� E4aDATE81(�UtED(MO.,Day,Ycj a4hTIMEt7FDEATH. -
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<br />asan�oFOemH ��� aaarmoeouHCeoo�ro�ao.,oay,vr.� xad.rmaeraowouHCeu�na
<br />8:40 m � « ' m
<br />i at ihe , dele erM place � � 24e. Un tlre basls of exertd�retlon aMlm InveatlgeGOn, M my opirdon deaih a�urted et
<br />end Titt � � 8 �. v�e ums, date and Wece am� aue ro me ceusela} sre�ed. (alg�retureand nue 1♦
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<br />28a.HA90R0AN0AT198UEDONATIONBEENCON8I0EHED9 28b.WA8CON8ENT�RANFED?
<br />00WN ❑ YEB NO Not Ap Iloable H 28a ie NO O YES NO
<br />EBb. DAiE FILED BY FIE��STRAR (bto., Oey, Yc)
<br />MAR 6 ZOD8
<br />�s-er �7roa(ssosi�
<br />MAR 0 6 2D08
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