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<br /> N ' wr�n�rs c�r c��s rrE Rivsev s��oF rHe nreeRi�sru rr��n��H�ni ssg.�wces
<br /> � S1�STEl1�!T CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIO�Vi4(,
<br />� � THE NEBRASKA HEALTH ANO HUMAN SERVICES SYSTEII�VITAL STA€� i� �
<br /> O _ _• -- �
<br /> THE LEOAL DEPOS/TORY FOR VITAL RECORDS - "- -
<br /> t �! -�= 9 .�ososs d
<br />� DATE OF/SSUANCE !� '�,�`�^ 9
<br /> ���=����ANLEY S C `-=
<br /> FEB 2 � 1998 Q���
<br /> AS�STANT STATE RE(�EfSTRA�t
<br /> L/NCOLN,NEBRASKA HEALTH AND f�tMAl��`$yg�M
<br /> S'fATE OF NFBRASKA-DEPAR7'MENf OF HEALTH AND HUMAN SERiR�R�AIdCE�PppRT
<br /> VITAL STA77STICS =_--�-`°=-�"
<br /> CERTIFICATE OF DEATH
<br /> 1.DEC[DENT-NAME FIqST MIDDLE UST 2.SE% 3.DATE OF DEA7H /MOnfh.Day Year�
<br /> Charles Glenn
<br /> a.CITV AND STATE OF BIRTH lpncl h U.S.A..nems counhy) Sa.AGE-Lest BirtlWay UNDER 1 AR UNDEF 1 DAV 6.DATE Of BIRTM /Mprllr,Da.Yeai)
<br /> Kenesaw, Nebraska �YfSI n5 Sb MOS ' DAVS Sc HpURS' MINS.
<br /> � April 3 1921
<br /> 7.SOCIAL SECURTIV NUMBER 8a.PUCE OF DEATH
<br /> � 5 0 7-0 5-6 4 2 4 HOSPITAL � InpalieM OTHER �Nursing Home
<br /> --- - a
<br /> Bb.FACIIITV-Name /Mndinsl�Iion.yiysheNanynu�M�rl � EROulpeMerM q�p�� .
<br /> . ---Rene sa _ n �A (1 0„�„�,N,_ ____
<br /> 8t.CITV.iOWN OR LOCATpN OF OEATH 8C.INSIDE CIN LIMITS Be.COUNTY Of OEATH -j-
<br /> Kenesaw Yes � No ❑ Adams
<br /> 9a.RESIDENCE•STATE 9C.COUNTV 9t.qTV,TOWN Ofi LOCATION 9d.STREET AND NUMBER /lncNidlnyZp Codel 9e INSIDE CITV LIMITS
<br /> m Ves� No a
<br /> 10.RACE-�s.g.,White.BWCk.American Indian. 11.ANCESTRV�e.q..IlaFan.Mezitan.Garman,elc� 12.❑MARqIED �WIDpWED 13.NAME OF SPOUSE /l/wde.give maiden name)
<br /> e�c.11SpeciNl ISOecdyl `O NEVEF
<br /> Wh i te D�VORCED
<br /> 1<a.USUAL OCCUPATION /Giw kindd�rork eb�p oUhg mpal ��/� 1tb.KIND OF BUSINESS INDUSTRV \\ 15.EDUCATION �Specily only Iwgl�eyt qrape tomplgl9d)
<br /> drarkmglAe.9wnArefiieyl 1 !1 EkmeMarypSecondary 10-12) Cdbge Ii.aaS•i
<br /> 'V
<br /> 16.FATNER.NAME FqSi IMpp6E U �i 7. FIRST MIpOLE MAIDEN SURNAAAE
<br /> Samuel A. Westin
<br /> 18.WAS DECEASED EVER IN U.S.MMED FQqpES? t9a.IN ORMANT-NAME -
<br /> IVes.no.a unk.� pl yes.grve war ane ea�es d serviees)
<br /> No
<br /> 19b.INFORMANT MAILING ADDRESS (STREET OR R.F.D.NO..CIN OR TOWN.STATE.ZIP�
<br /> 15 10 W 94th Street---Prosser Nebraska 6
<br /> 20.EM �ER-SIGNAT RE 8 LICENS 0. 21 a.METH00 pF qSPOStT10N 21b.DATE 2tc.CEME7ERY OR CFEMA70RV�NAME
<br /> � � /l I �Buriy �Removal
<br /> 22 UNE E-NAM 21d CEMETERY OR REMATORV LOCATION CI7V OR TOWN STATE
<br /> J son-Wilson F.H. ❑���� ❑�a�� Kenesaw, Nebraska 68956
<br /> 22b.FUNERAL HOME ADORESS �STqEET OR R.F.D.NO..CITY OR TOWN.STATE,ZIP� �
<br /> 209 N. Smith Avenue Kenesaw, Nebraska 68956
<br /> 23. IMMEDIATE CAUSE (ENTER ONLV ONE CAUSE PER LWE POA ial.Ibl.AND(q) I Irnerval benveen onset anC Aeam
<br /> PART .�
<br /> 1 �.rv�{/'�� `�'V--• I .
<br /> lal �
<br /> I
<br /> � DUE TO.OR AS A CONSEOUENCE Of: I MNerval pMwaen orrel aM Ae�M
<br /> Q..�.�-u�?. Ac�l.e�'�-� W-� O�,D.co� C E�"� -- -- __ ..t._..... -
<br /> (D� �
<br /> I
<br /> DUE 70.OR AS A CONSEOUENCE OF: i Imervai be�veen onsei ana deatn
<br /> i
<br /> 'cl ,.�" �
<br /> I
<br /> OTHER SIGNIFICANT CqNDITIONS-CdWdions c�pMribuGrp p�hg Cgath bul nq relateG PART III IF FEMALE.WAS THERE A 24 AUTOPSV 25.WAS CASE REFERRED TO MEDICAL
<br /> PART
<br /> �� / PREGNANCV IN THE PAST 3 MONTHS? EXAMiNER OR CORONER�
<br /> ✓ '�V'"`�� (nges�tr-5a� ves No ves No ves No X
<br /> 26a T60.DA OF INJURV ..Day.Yc/ 26c.HpUq OF INJURV 26d.DESCRIBE HOW INJURV OCCURRED
<br /> � Accitlem � UnOetermined M �
<br /> � Su�eWe � Perpirg IIQS:INJURV AT WORK �26L INJURY• farm.streel.IaCWry 26g.LOCATION STREET OR R F,D.NO. CI7V OR TOWN STATE
<br /> � � ❑ �"���.�. ��'
<br /> � Nomiclde tnv85Ugation Ves No
<br /> 27a.DATE OF DEATH /MO..pay,YrJ 2Ba.DATE S1GNE0 /MO.Day YrJ 28D.71ME OF DEATH
<br /> February 15, 1998 ,<w M
<br /> �$u�i 27b.DATE SIGNED /MO..Day Yr.1 27c.TIME OF DEATM �ii'K Y 28c.PRONOUNCED DEAD IMO.Day.Yc) 28d.PRONOUNCED DEAD /hburl
<br /> �� <�
<br /> ��� February 17, 1998 5:00 P.M. M �_��
<br /> g M
<br /> °� 27tl.To tlie Dest d my knowbtlge.OeaM occurre0 at the time,date and place and due to Ihe ��� 2Be.On the basis d ezaminatan aM�or investgation,in my oqNOn Oeath ocwrretl a�
<br /> tause�sl slated. Me time,date antl place antl due a the causelsl stated.
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<br /> �S naWre anE Tdle/ �S�nature and Title
<br /> 29.DID TOBACCO USE CONTRIBUTE DEATH? .a H RG OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTE07 �
<br /> � VES NO � UNKNOWN � VES O NO � YES � NO
<br /> 3i.NAME AND ADORESS OF CERTIFIEA IPHVSICIAN,CORONER'S PHYSICIAN OR COUNTY ATTORNEVI lType d Prinp
<br /> Kevin W coff M -1
<br /> 32a.REGISTRAR 32b.DATE FILED BV .qy. c/
<br />,yoverruY�ent I,�ts Four (4) and Five, (5) , incl�li.ng any accretions thereto, in the 1�Torth�a�est Quarte.r
<br />(NW/�) and tha� part of the Southwest Qua�ter (SW/4) lying North of the Union-Pacific Railroad
<br /> Right-•of-Way; ar�d all that part of Lot Three (3) which ld.�es West of a line drawn parallel with the
<br /> West �undarv line of L�t Twn(21 extend�3 North to the Nnrt-hPrlv Yirninr3arv line of Tnt Thr� (�1 _
<br />
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