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� "" STATE OF NEBRASKA � ' `` �
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPAR'TMEIV�b� �I�A'L`�l� NL7 ,
<br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BEA TRUE COPY OFTI-fE_�Z)RI�TN'A�LrV2�C'yQR�1(,�N
<br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVIeES VITAL' �ECORDS a -
<br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS ", �" ��' `�),�" ° � r ��
<br />DATE OF ISSUANCE � A" � ��� L�
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<br />e!�! � a���'! t� A.SSIST34{VT STA'1'�''&�GIS�4?AR' �
<br />2 0110 9 0 4 9 ; ; N`f��P�IRTMENT QF HEAL'TH �1N�
<br />LTN�OLN, NEBRASKA , HL��IAN ��R �/FC�S f F�� , ;-.
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<br />eu�� oF viTU� sr�T�sncs Y' '���. ' 9 0 Q 15 3
<br />CERTIF�ICATE �QF DEATH � ; ,�; �
<br />OECEDENT-lVAME FIRST A41DDlE LAST SEII DATE OF DEATM fMo.. Dor. Y..) i
<br />I i. cRNFST M?LTVN RU�� �. MAL� a. APR.
<br />29 1979 �
<br />�ACE-(�-9•. YVbIt�.6laek,AaN►kan OR161N/DESCENTI�.y.,Italion.AA�aieon, AG!-tmtsire�y UNDER 1 YEAR UFIDER 1 OAY DATEOFOIRTFI(1No..po�,rr.J
<br />- i�wliea. Nt� ( Sp�ei/p) C+�naan. ��e.) (Spaci/p) s (Yn.) MOS. � DArS MOUlS � MINS. �
<br />.. UlH11'� --- s. _ AM�'RICAN ;� �' �. 6l bb. � a�. � ,. MAR. 29 1418
<br />C11r ANp STATE OF OQTM (H aof in U.S.A., CITIZEN Of WMpT COUNTRY MIARp�Ep, NEYER MAARIED, NAME Oi SpOUSE fN�, oiri wnJdew wo�� �
<br />aar couintryrJ WIDOWED. DfVORCEO (SPK�Y1
<br />a. MFRRI�CK _CdUNTl�. I�€8�. 9. US�I �o. MAT1tIE� �,. 6'IOLA SCHII�{FRS�IAL
<br />SOCUI URtTY NUMb USUAI OCCUPATION (Giw Yind of worlc dorh during mou KIND OF 6USINF55 OR INQUSTRY COUNTY OF OLATM
<br />�.o.ki �ih. .w� N..h..d) D��IG�
<br />�z. 505-16-73_�S ��. �ARP�ALT�R � ! � 136. I,� P. RAILROAV �b.
<br />CIIY. TOWN OR IOCATION Oi OEATM 1NSIDE CITY IIMITS MOSi1TAl OR OTMER INSTITUT1pN - Nuay (1/ imt in eit6t►. If 1105►. O� M1Sl. I�d'icati OOA,
<br />(Sp�ci Yp or Nol gJw �hsd ond n r ��b". �' .�'�w lSa.uirl �
<br />�,6.-- ,k. ,.a. ST. .7 NOSPITAL ,...INPA?I�T
<br />RESlOEt�E-STATE COUNiIi CIIY, TOWN OR IOCATION STREET AND NUAASER I�IDE tiT1► WytTS
<br />�so. N��RASlCA ,eb. HALL �x.GRA11tD ISLAMD �sa. 308 UJ. 17 ST. ���°`►�'
<br />FATMER- FI T MIDDIE T MOTNER-MAIDBN NAME F RST MIODLE 1
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<br />,b._ PAUL � . MIAINI� R�tfR �
<br />wA5 pECEAgEp EYER IN U.S. AItMED f0110ESP INFORMANT-NAAAE-REUf10NSl11P-INAIUNG ADDRESS �srelEroR ir.o. wo.. cm Oe rowN, srw�E, zvl '
<br />(Y�t. ero. a un6) I(M yn. 97.� .+or ond don� d w..is�1 . I
<br />�e. Ntl _ �__ �91lIOLA R I� $ W 17 S"!' GRANU ISLAND AI�. 68fs0 �
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<br />BURIAL, tcemqtion, Remoral DAT � f� 1' n CEMETERY pR CREMATORY-NAM IOCATiON CITY OR TOWN STATf
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<br />-SIG TUtE 5 NO� FUNERAL MOME-N,UNE AND AODRE55 �STREET W R.f.D. NO.. CIi1r Ot TOwN. STATE. 21/)
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<br />� r �) aea�d� �• d�e16 oaur.�d el Nw�. deM aad plac� oad dw ro Nu On fAr bmb ol uaaiaoHen nad/er inwqiyafio�. is �r epiaia� dw�A eccwwd a�
<br />/ Z� eM Hm�. dat� mid plot� md dw b tlr sa�r(t1 alaNd.
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<br />��_ DATE 51GNE0 fkto.. Dor. Y..) MOUR DEATN �� Mo. r. r.l
<br />�<;.
<br />�.� z�,. 5-10-79 z�. ?:00 M��� Y46. 2�e. M
<br />�� DATE Of QEA7M (Ab.; por• rr•1 �go PRONOUNCED DEAD VRONOUNCEDDEAD(1lar.)
<br />~ �p (Mo..Dor.Yr.)
<br />r.�e, _ Aar i I 29. 1979 �$
<br />21d. 21�. M
<br />NAMIE AN ADDRESS Of CERTIPIE (PMYSKIAN, CORONER'S PMYSICIAN OR COUNTr ATTORNE�) (i�ps or Prin�)
<br />zs,_ Michael �,7. We er .D. 6�f3 Medical Arts Ruildin Omaha NE
<br />REGISTtAR DATE RKEIVED s 1 (Mo r..1
<br />z�.,��..,► � y �� � � �Cd� �"� 1 ��''
<br />466.
<br />Y7. IAIAIEi11ATE CAUSE f ENTER OMLY ONB CAlD56 RER lINE iOR (a), (bl, ANO (�)/ � Intnwi bMw�n onwe ond dwN�
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<br />�o� Cardiac Arrest � 15 minutes
<br />DUE i0. OR AS A CONSEOUENCE OF: ���� �����
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<br />�b, Post Operative carcinoma of es�phagus and lung � 6 weeks
<br />DUE O. OR AS A CONSEOYBNCE Of°: . Inn�rel b�+�«n eiup a�d dwM
<br />kl �
<br />P� 6�E� SI6NDItANi CONOIfIONS—Ca+diHon' conMbntMq b d;atb brf nof rdobd ►A!T 111 11 fEMAIE WAS TM[�E A AUTOiSY WAS CASE REEENEp Tp /AEpICAI
<br />Q � rREdNANC� IN TN{� ►AST S MONTMST (Sp�tilp,l'n w NoJ E7fAMINER OR CORnWE!
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<br />-- ��� I Ne ( J IB. �� 29.
<br />•CCIOlNT. SYICIOl. MOWCIDE, UNDtT , pATE O� INJYlr �Mo., Oo�. Y�.1 MOU� Of IWU�iI OfSGd/E NOW INJWM O�CU�!!D
<br />Of rlNOINB IMIlSTi6Af10N PSOKd►1
<br />- �O' �b• 30e. M 30d.
<br />IWyRT AT WO� ►U1C! W INIU�— A� heM, larw. UrNt, laelpry. laAilON SfREE1 OR R.� O. No. Clit OR TOWN STATE
<br />Isv.��y r.. w+YeJ oNk. s�ildieo, qa �sp«rlrl
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