|
: . .
<br /> t_..��.1"v•,..'4"� � ' ... . �t...Y::_ �..._...,` `. ' . . --'3w-- _ _ `L� _ - ..C_.4Z� �, t_t:'.'�`-
<br /> } ,
<br /> • .. . �
<br /> . T, .. . , ... , . .... .. :...L.� �._t -
<br /> �� - ( J .. — -- __ — _ . - __ — _ .i. _ . .
<br /> ..' -c ..: . s i�" - _ c i .
<br /> .
<br /> � .
<br /> �, - �� r.. 5 j��,c c � �._ c -t ` € -
<br /> cd c z . _ � �� �- , c S -c `�.�. -
<br /> ..r`� .i,.t,. .t .. , _ . �� . ' `s r -,.. f .r �. _ F
<br /> ''r' ' .` - . . _. .. •s . . . , .�'s-.,F' ,t "c .. 'a
<br /> «_ _ � : '�• t` r'� t �.�� � _ _ . '.r �
<br /> '<'. , � - � _ . - . . _ . _. . .... t . � -�t� .. Y�� _ � ' t_,
<br /> t ' � � .� . - . . . . . �..
<br /> i � � `F� .. Y .u � '`� „r ` .. . . . . , � .. _ -
<br /> � . -. � , . , ; � �`• . : .. . .. .c. c � e.: .
<br /> , r . ,. ca ��.c. - . - c � . _ . . ' ,� _ _ .z'
<br /> , . � .. .� .. . • • ,. .. ��i` •� ' - � .. �� � . . - - � ' �` , � , .�c',
<br /> . . . . ' .. -C,' .. , � 4 , . � ' ••� � � .. � ..�• � , . _ .' ' .. * `• �C. � t �_4i' L tf�.� .
<br />. . � , 4� � . ' . a • ' ; k � • f . 't �r . Q . `� . 4
<br /> � _ f'. . . _ . L .<- S, _ _ s.. 'c _ _-- .12' , a.
<br /> .. � . >r� � � -.z , � . . . . -°'
<br /> .. • - . , _-..,E . ._ . . . .
<br /> �. � STAtE CF tVEB�ASHA—o�aa��r oF eaEa�TM �,����.,� � . .' . .<. :
<br /> . � eu�rw oF vtire�sTans��es � �� .
<br /> . . °� ` . CE�tTIFtCATE�F�EATI� ..s�.� ' . . � ,:
<br /> . . . HRSf D O� /O TM Ma. o�Y�.1 °,-
<br /> OECEDE -NAN![ ` �' �' -
<br /> _ :� .. John Al��uder Smnllen , 2iaZe d:nuaxy 30, 1979 � << < � .' �
<br /> � . �� w��(�.¢.W in.S ock p��s�{6�}up�te�Rli.g.,iroliae,64sicaa. AGE-Iw O�1Mdo� UNOER!ItEAY UNOfY 1 OAY OATlO/BiYTNfMa.Cor.T�.) �� :
<br /> i .,..m- c��..�.usD«fi, r.�., Mos ; oA�s «o„�s; «��,s_ Feb. 4. 1923 �,
<br /> � ,��..K..t�S"V��+�r, 55 a • _ -
<br /> �:- �liztte � dmericat� : e0. �
<br /> -- �— --'--- qTtAHDS ATEOIBIY7Nf mtisU.fA-. OlW1G1tOtltfiiY MA4IIl�i�YEIIMA4Q1fO. lfAMfOl, USEtil�i�.9hsarol6�eeam�l�nA1�9t1 � .._ -- _� - -� - .
<br /> . ,. - , eam�tou 1 V71D01NED.OIVOCCEO(SP�dh') � t`. _.��� .-_.�� .
<br /> . °.s Ce�c ar Ra.Aids t7a. 9. USA ro. i�la�ied u Ric�ri.e Eilaen T�eistex , � : t= �
<br /> .. . � - � SOWISECYR17rNY�m ifS11ALCCNPATIdN(Gtwtiedot.orldo.uAv.inpmo�t t1►tII0►SUSiNESS091NDUSTNY COUNROPOlAiM . �. ,�
<br /> ' -'} � -' ohodi Ch.Franilr�find) •� . - ' . .
<br /> , ,. r` � 0'—18— nd �ssemb �aa.f iautifi►C r.o. g�7. � `r a�
<br /> _ ..c� - ,,i -, �mwe�ontoGltONOfOEAn� (N57GEGTYUM7iS MOSVRaLOQOTMEQIt�STIM�Oh-Nnm�plaoltndl6�r, anov.awsr.delia.ao�► .
<br /> - (S YHOr1YO1 Ota�dmofe 6�r1 ��i�eVfa+��0a.tpeY�n�llps4) " ,• •
<br />- . Grand IsZarui �.�.°�`�`es ��a.St."�raua3.s i;�die� Center ,..Er.�er nc b2ooa , f . .�...
<br /> . . . , - � RESiDENCE-STATE COUNI1t Cli�.tOWNORtOCA710N STQEETI1dDNIteeBEi INSIDECRTl1MRS ._ ..—.�c_--
<br /> /dy�ci�norHe) ' �. __
<br /> - '` �sa Neb]Caeka �ss. H�.72 �s�. Granci Islsnd . �se.1 11 No. Rub ��.. es . :�'" �' ,�,,.• "
<br />� �� � � ' - A M Q- MtG MO D NAME IYS - ' � f---_
<br />.� John Smollen Tillie m�,�„a„A�t ---
<br /> - WASOECEASEDEYECINtfS.AiMEDiOIICES? INFOBMANT-NAMF-tFlATIOHS!!fD-MA1tlN6A00QE35 Ri�i07l��NO..aS/OttOwt�v► -
<br /> - . . � ItrM..o,a�a+fl OI f�.9^��•md aom A w.n�.) -
<br /> ' ,a Zlo �v.iUes. Fiarie�Smollen NiYe--7. 11 Id. Rub' Grand Isl Iie
<br /> , � , • • . BU0A1.Cnmation.Rsma.at OA CFMETEYT CRCAFMATOYY-WUNE LOCAIIQN �lSI�OItTOWN STATf `.c i�. ,� --
<br /> f ` • :os. 2 :o�.Gr�ad Zsland L`3. soa. Gra�nd Island 2JE .;" �---..--
<br /> . zoe. 68802 .ti. f -
<br /> ---• ..... -c:� _ - dNEAtMER-SfG,NA.WE 8 tl ENS N �� iUti MOMC-NAME AND AODRFSS (STQ[tt Ol t/A NO..Cltt Oa TOW�L SU1iR Zf►/ ` _ — _
<br /> .� ^'qy".:'' . Y..
<br /> � " vin torrSo de ssru' U Koe ' Gr Island iie - . . �._
<br /> .' , ::s:; � r.�s.a.n�a.y �e.ona�.�.e �..me.a.aaawaam,.a�s. � ae»eaw.�m.�.eeo,.a.e�ubma��.+� aowe.e.oeew�.em ; —i_
<br /> m�+4fpettl. �� Mpr,dM�ad9bo�mddwbfl�m�wLO� '�'' � �
<br /> , � - - � ,/ � /y�� �� 2b.!llOaaM�emlfltl�)� � . .� ` �.j�._'_
<br /> .. �yt pJ6.! odTiW� OU �OEATM A � �y �� ` .._�_. .
<br /> - ' ,� OATE t ED fMO..Do� rJ <
<br /> 8:35 P.M. M r��s.a t�. . �.. A:�
<br /> � . , .. _ b' r.�d °7''�-7 —
<br /> �to- M -��
<br /> - � . ���b PQON UHCEDOGO iQOMOUNCEDGtAO(Ho�i) .
<br /> 3 pAfE Of OEAM(Aq�.,Cnl.Y�•) o �+ (Ma,Ro�,Y�.) --
<br /> � s s
<br /> . . � . . .:3��e.
<br /> . . °�� � . _=,
<br />_ �{.� " ' _.. ' NAMBAN AO R 7G IfiHt(i SICIAN.COAONEY'SV IWNOYCOUN/YATTOANEqIT�pvorVdnf) ..�", .,.':.,' �.-
<br /> �_ , . ., , ��� Q sen 21 D a b t �'rancia l�Iedioml Center Grartd Ial I�e. , ,.. :_r�„ y-
<br /> . - � . E 57t11R . D TB 4E IYED Y YE615TRAR(MO..Cor Yr.) ry
<br /> . . /]/jn . i .r
<br /> ��if j I 6. ,��
<br /> -� 2an.xc•v+�•�� . e.�r..som�lece - '
<br /> � �` 27, IMMED ATE GAUSE !E Ei ONtY ON CAUSF PE/UNE f0�fo),(bb AND(c)) � - ;y�.
<br /> ' . 9� � ' , , -�—.
<br /> o) � htiwalMewMananmdd�o0i ` - ---
<br /> _ . .._-. _-°. .: .---. tl . A CONSEOUENCB O!� _ � . . ��-� � - ' __�
<br /> • . . . � '- �. . '�ys rr--
<br />� - � - �) • IW�IO�MMOnntwdd�o�M . .. .. . .. �.�F'�-
<br /> ` � - - . OUB TO Oft AS A COHSEOU W CE OV, � „ - �'�'
<br /> '' . �� . � � �.� _ • ' f�_
<br />_ �
<br />�"-.�. . . . . , . p�OiMtY516 TCONDIt10N3-CoediNr�vnmEN�W�ad�a�Mn�ofe�Md �lt6�HAHC11Ni�N1►AST�MNSt Ifp�il�I��aHe) wlIfAWNt!1,COWNTeO�YlGI { • . . ..
<br /> . . . .. - ' Il . (f0YN1TUaHe1 . . . - _ T
<br /> � Y�s❑ No O se. .. ,
<br /> • - � - . . ` � ACpDtN1.IIYIGO4MOWGObYNqi. OAflO/IN1YtY(/RO..Ooy.T�.! NQU�GIWUI► 9LSGf10�NOWUDVtTOCCY�2W ' .' : ' ( �" _
<br /> • �� � - pf/D701N61M�E6110�TION./fYwN!) � _ . ��. —'_
<br /> �� � aoa. aab. so�. M soe. : � , � �
<br /> _ , . . - -. , .. �,f i un�iwoar q.eeaw,u� - r om•.o�...mwc �,.�ery. �oanou itnao�a.aete. ottoatow►� sfwn . '. - , . .
<br /> , q�Rily Ip er No/ a11tw Orildiep.pc 1lOnNyl
<br /> !S. ._. . _. ' "—_ 30n �0/. , I =
<br />. _- . . ' , . . . .i.. „ ��o,. .. � ,. . � .. . '�
<br /> -- ' � .WHEN TSIS COPY CARRIES THE AAISED SEAL OF THE NEBRASRA , ' , . -.»=��-«�-
<br />- � � �' ;;:STAT�E DEPARTMENT OF HEALTB, IT CEATIFIES T�E ABOVB TO BE � � '
<br /> , �, • " a.' : ._
<br /> � � �� A TSUE COFY OF AN ORIGINAL RECORD ON FILE WITH THE STATE . �. �
<br /> • � . � "•DLPAIt�MEN� OF HEALTH, BUREAU OF VITAL STATISTICS, tJHICE . .� . .� • °
<br /> � . � I$ 7�HE .LLGAL DSPOSITORY FOR VITAL RECORDS. . . . �, ,. ,
<br /> , . ,. • . . .,
<br /> . i ' r ' �.GI�N:.i�i' �� .' � . • • � ' ._
<br /> • ' DIRECTOR OF VITAL STATISTICS AND ASSISTANT STATE REGIS�RAR � • �
<br /> � LINCOLN, NEBRASRA Issued February 2t, 1979 � - ,' � �
<br /> �._.-_.— . . `' : .
<br /> �
<br /> - . . _ �.,. — ,.--�--...,--� .. . . . . .
<br />`�; ` . . • . ' ' ' " ' � . .. . ..
<br />.�, .. . . . . . �; - .
<br /> . . � . . . «
<br /> � • � . ' � . '. . . , . ...� . . �,---r�+-r-F-- rr;;:7�r.y.:;r•.,;:_
<br /> ... ..._.. . . , . ., . ..... ' .� '. . ._•:cti�._._.._.,__. ....__ .._._.._.. ..___.... ...:� .__ ..� ._._.w.... � .., ._... _.�._.._,_.... ..� � , . • :..._�._
<br /> . .i: _ :_`.u..L._.._�''�� .al:._ ,a_.:::�....V
<br />
|