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<br />I
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBR4~~ STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW.TO, ~E ft~RU.E COpy
<br />OF AN ORIGINAL RECORD ON FILE WITH THE S1'ATE.PEPARTMEPT,OF,HEALTH
<br />BUREAU OF VITAL STATISTICS. WHICH IS THE LEGAL-'nEPOsIToit~rFoR
<br />VITAL RECORDS. . ' ~
<br />
<br />88- 101385
<br />DATE OF ISSUANCE
<br />MAY 1 8 1981
<br />
<br />I
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />~1~.
<br />
<br />STANI:f~ ;<~. CO~P~R ._-~JRECTOR
<br />
<br />1- .. '. - -
<br />BU~,!'OF'~!T4L STATISTICS
<br />
<br />
<br />fllST
<br />
<br />STATE OF HE.RASKA-DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH \. :,~ 'I
<br />MIOOll lAS Ul
<br />
<br />August 31. 1914
<br />
<br />Ub.
<br />lESIO!NCf - STAff
<br />
<br />Nebraska
<br />COUNTY
<br />
<br />Ilb Stuhr Museum uo Hmlard
<br />
<br />HOSPitAL 01 OTME_INSTITUTlON _ NafM' ", AO' if'll..'''.'. ., MO!t'- OIIN5.I_ INlic.. OOA.
<br />Outp....""''''"r ... .....'i....'-(Specrf,-J
<br />
<br />U. :uu>ati.ent
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<br />dO.lard
<br />"\loon
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<br />420 Jay Street
<br />'liST ""DDlE
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<br />IN510! CITY liMITS
<br />(Sp.f.r, ,~O, Ho}
<br />IS. J.es
<br />lAT
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<br />SlUff AND NU....U
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<br />16. (dec) J\lois
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<br />WAS DfC!ASED (VU IN U 5 ......ED fOIUS?
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<br />Sawicki
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<br />CITY 01 TOWtoI srAn
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<br />1000, Burial :lOb. 5-12-87
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<br />Jacobsen Funeral. Home 411 "0'" Str. St. Paul
<br />OAt( SIGN(D (Me Do,. "J HOUI OF DE...TH
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