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. . WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COPY pF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT OF HEALTH • BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. -_- --- � -- =- CE �.- Ga��. DATE OF ISSUAN :__ AU� 20 � STANL�3€_ � _G`�QPF�,��R��R - - - � LINCOLN, NEBRASKA BUREAi��F.a��AI. �T��ST€CS ` ' . � ��_-. ��f��0� STATE OF NEBRASKA-DEPARTMEHT OF HEALTH BUREAU OF VITAL STATISTICS,. � cEan�cAr�oF c�r►�+ - , � t�, ' FIRST MIDDLE LAST 2.SO( 3.DAT�OF DEATM (MO�NN,DaY.Y�arl t.DECEDENT-MAME �11 . F�."le August 13, 1993 Retta Sue �� Y �. 0.DATE OF&RTM (MakM1.WY.rwl !.CITY AND STATE OF BNITM lMnOf h U.SA.rwrM eanl�') n,., SE. Ma.i DAY6 Se.FIOU I MINS. V�.t�L� GZ/ 17�sc7 Grand Island� Nebraska � � ---�- 7.SOCIAL SECURITV NUM9ER !a PUCE OF DEATM FIOSPRAL ❑�nWd�rM }�XER�OUW� ❑DOA � � �� „�505-7 2-47 7 a� OTHER. o N�w� ❑r+�•^�• o om.��sw��r� !b.FACILITV•NYM /M not inpiMion.W�"I i6�N�nd nwnW�i Bc.CITY.TOWN OR LOCATION OF DEATH �'�N��p a IVa�S M.COUNTV OF OEATN Yes Hall St. EYdriC18 Medical Center Granc7 Island' NE 9e sr�t�u+o nu►�e�+ �u�cwaw nn�� w.u+aoe cm wars ic.CRV.70WN OR LOCATION �SPkM'Yw a Nal p�,pESIpENCE-STATE ��"T'� 2136 West llth � Yes Nebraska Hall Grand Island 12 YMWED.NEVER AAARWED, 13.NAME OF SPOUSE Ip�.0!w^��^"�l t0.RACE•h•0.WldM,&�ck Mwiem InMn, tt.MICESTRY I�.q..luY�n,AAuw�n,O�mrn�M�.� ��yEp,DIVOi10E0�/�MY1 .�arsw� �s�"r' p(, Nlarried B an Hall White American 14D.�K1ND OF BUSiNES51NWSTRY E��ry a�p�p�y(0-t2) I CoIMp�Il-a a S•1 1��.USUAI OCCUPATION(f�M kin0 d wak d0/y dmnp mor� � Z d'"°"`��.''""��"°' 3l3 R E A y �Jo 12 Secretary FIRST MIDDLE UST t8.FATHER-NAME FIRST MIDDIE IAST 17.MOTMER-MAIDEN NAME Henry -- Wiese Elsie -- Orash 16.WA3 OECE�SED EVEA M�U.S.ARMED FORCE37 19.INPORMANT•WUAE•AWUNG ADDR�SS (STREET OR N.F.D.NO..CITY OH TOWN.STATE 2I I rp,^°,"°"`, ,"'"��"""°in°°�°`a'""`"`� g an Hal l 2136 W 11 th Grand Is land, NE 68803 NO pp.�p�ATIpN CITy pq 10WM STATE 20C.CEMETERV Ofi CREMATOR�-NAME ZOa BURIAL Cnm�tion.RMnwd. 20b.DATE - Don�tlon Burial Au . 17, 1993 Grand �sland Cit Cemete Grand Island, Nebras 21.EMBA . R--SICM�T�RE+U� E N ' �1�'r �FUNEHAL 110M�E-NAME AND ADORESS �STREET OR R.F.D.NO.,CITV OR TOWN,STATE,ZIVI A fel-Butler-Geddes 1123 W 2nd Grand Island, NE 68801 � im.��w�w..�a�,�a a..m � �ENTER ONLY ONE CAUSE PER UNE FOR�a�.Ib�,AND�ep i �p 23. . � /vi.:•-� PART � /� i �marvu w�w.m a,wt aoa awn WE T0,OR AS�C� ENCE OF � I I li�tervi!bYAYGi(1�f.9Yi 3R4 O:.CiR - - WE TO�OR A5 n COii6eWEf/CE OF:� -'. . � I I OTMER S16NIFICANT CANDITIONS•Co�ditla�s�^�^4 b��ro� . PART III iF FEMALE,WAS THERE A 2�.AUTOPSYa a Nol .�.�M��E��ER7�� PHEGNANCV IN THE PAST 3 MONTHS7 ISPk�M �g�ryy Ya w Nol NO PART Yes❑ NO '�S II �ORCPEDNDIN(i INVES�IDRrU�j. Tlb.DATE OF INJURY (MO..Dey.Yr.J 28e.MOUR OF IWURV ZBd.OESC E HOW INJURY OCCUR ED 28a.�NJURV AT MIORK 281.�DuilCirg,Na I A�MI'hrm.stresl Isctory. �� LOCATION STREEf OR R.F.D.NO. CITV OF TOWN STATE I�M'YM a Ngl CJ 28D.TIME OF DEATH 28a.DATE SIGNED (Ab.�D+Y.Y��l 27a DA7E OF DEA7M �aa.,ar.r,.�/ 3, /�� � _3 = .s�/ti �.4�� a� r - � 28c.PRONOUNCED DEAD l��pY•y�/ 28a PRONOUNCED DEAD (MOw) a 27b.DATE SIGNED /MO.,D�y,Y��I 27c.TIME OF DEATH t`� � S � �ti ��- �5; ��g �3as E�� 28�.On tM Wis d�aamin�don�ndlOr invMUqNiM.in my cpniM�d��l�OCCUrrW q s� 27E.To nr bM d my Icno+'MCW.ONtl�atume n tirt».e W�u Aw s tl»tam.e�a ana D��nd Cw b tlr cwNis)wtW. Q uwNsl� / L� •uW Titls �aM TMN► 2p�.dD TOBACCA USE CONTRIBUT TO THE DEATH9 30a MAS ORGAN OR T�SSUE OONATION BEEN CONSIOERED? 30D.WAS CONSENT 6RANTED. � VES ❑� ❑VES ❑VES NO ❑UNKNOWN . 31.NAME AND ADDRESS OF ERTIf1ER IPHYSICAN ORONER'S PMYSICAN Oii COUNTV ATTORNEY� (Typ�or Prrnf) Dr. Carol hackleto 26 West Faidley Grand Island, NE 68803 32D.DATEfIIED�G�ST�q ��r�� 32�.HEGISTMF � 1 �