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<br />� STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARf.P%FE�� �I�VD
<br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF T�,O N��.R��QRlJ @)�1 .:� '•
<br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SEF�,�1%��'S,, ° tl�,�C ,9�E�tfRb.� �
<br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORD�5 : r.+ R ; � �� '� ' �'�, '�` �.�
<br />„r 4, " �.
<br />�.. � ,
<br />DATE OF ISSUANCE
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<br />�CT 0 � 2019 ( ,.� � d w, � ,� � ° . .
<br />I � I* � ,� , �S,rsraNT s�r�r,� r�€��a�a �
<br />LINCOLN, NEBRASKA � l� �� Q e� �����'4 N,� IVT, �f�� �A�T�`�A„1�` D
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<br />� DaP OF PUBLIC BEALTB.
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<br />,� s�rs xo.126.._..... CEBTIFICATE OF DEATS sTw� � xo.........___.
<br />: t. !u►ct �' �urn Z. ufYAl. �[M�(I�..l.r...rw.r. ��i�OCw.�: s.ri..o��/in.�.i..bn) ...._.....
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<br />�. WTY. TO�fN. � l9CATiON t. LENGTN OF STAY IM ib t. CITY. TOWN, OR LOCATION
<br />i �rand Island da
<br />= t. NAME OF (IJ'AOt is �0►pfht. flvs atTtt! Ad�iEtt)
<br />H�66PITAL OR
<br />i II�TITUTIOaI S't � L,� a. ��
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<br />� e. IS PLJICCE OF DEATN INSIDE CITY IIMITST YES� NO ❑
<br />� 3. NAMt oF Fh� A!lllle
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<br />= t7Ype os priat} �� ��
<br />� g� � 6. COLOR OR RACE 7• PqARRffD � I�VER MARRIED
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<br />ta. cAUSS o� osArn [Ewee. m�t* oue caue pa►
<br />PART 9. DEATN WAS CAUSED �Ys
<br />,1. .- �, _. lMMEDIIITE CAUSE (�) �
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<br />atatla0 tAt uwder- DuE TO (t}
<br />` t�ep eauu tarl.
<br />� PART II. OTiER SI6N�IC�MT COl�IT1p16 �g
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<br />f �`—, 20a. ACCIDENT Su1CIDE
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<br />� 20t. TtME Of Hour MpstA, ,
<br />�ruuRV a. m.
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<br />� 20d. IMJUR� OCtURRED
<br />WMILE AT � NpT WHILE �
<br />�K AT NIORK
<br />2 � • ! stt�nded t6s deaeaaed
<br />Death accut»d �t __
<br />23D. DATE
<br />HOM�IDE
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<br />AoDRESs
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<br />soK �nousrRr i i. e�srHrucE ��ete o►
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<br />R'S MAIOEN MAME
<br />to o�rn
<br />DATE ](oW Dq
<br />OF'
<br />OEATH �� s
<br />AGE (I7t /CN� IF' IM10ER 1 YfaR
<br />li� Aht�II�IZ J/rv. A��
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<br />, Nebraska U.S.d,
<br />14. NAME � M�ANO OR N%FE
<br />�92'� '.�'qff 8 uC$OlI@v9T�
<br />�ueem No. n. tN�o�a�r
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<br />RELATED TO TNE TERMItLLL DI�ASE COlICITIDN 6lYEN IN PARi
<br />DESCRI� NOW tN,ttlRY OCSURREC. (Enter waNara ojfafv,r/ tA Pa►t !�
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<br />PLACE OF IN.tURY (a. p. 6� a a8pr� Aoa�t,
<br />!o►�.I�rl►� Kred. o�ta Wd/.. da)
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<br />(Dqrtt ar NNe)
<br />and /��t a�w� alir� on � '-'�
<br />f�bove; aad to the bpt of m� Jc+�whdN. lrom tf�� earisN �tated.
<br />ADDRESS 22t. DA7E SIGNEC �
<br />iAME�F CEMETERY OR CREMATORY . LOCATlON t�1. -���I ���)
<br />stT,a.wn M�emoria7. Grand Island " Aabr.
<br />WOO�'4lET� ��•
<br />p1TERYAL �ETIIIEBi
<br />� Alp 0 TN
<br />41"ig3.ri _ �
<br />24. DlITE REC Rj�ISTRAR ffi. REGISTRAR'S 316NA RE T6. NAME OF NORTUARY ADDRESS
<br />f/l ��-� Apfel Funeral �ome� 1�ood Riv�er� I�ebr. ;
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