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<br />STATE OF NEBRASKA-DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
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<br />CERTIFICATE OF DEATH t', ~~.:..~>
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<br />OIClCINI-HAMI "U' "'DOLI LASI' ffx JOAn O~OIAI" 1M.., Oa" T..I
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<br />.'.__ . J\)'J!~.rt__. . _!1erm~n H!I~i k tL-.l!'_~~ 3 A -r:~AJL-U!79
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<br />. ,,,hite 3 unknmm ~; 16. 62 eb: 6c : 17 ~Iay 5, 1916
<br />CUY ANO It,..." Of ..alH 01 ....". U i.t. I CIJlIIN Of WHAt COO"'UY MAI'lfD-, N(V,I MAllnO. INAMoI Of SI'OUs,( (If .it.. 91.. ",auf.. _alii.'
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<br />. Stuart, Nebraska ,U.S. A. 10 nwrried I1Rosemar A. Kombrink
<br />S,OCIJil.5fC:UI.fl NUIltlll IUSUALOCCU,.ATlONfC;.. ',,,4.1 '111'0'. J.III. dw,,1I9 "0" I.INO 01 eUSIHfS5 OllNDUSill COUNn Of DIAl"
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<br />17 505-09-4194 II'. Sal esm:ln '. ~. l3b Pharmaceutical 10. Iiall
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<br />LA~ll"OIHU ....lOf.. NAME f1R~1 MlOO\1 LA~1
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<br />~lartin Hamik J7 (dec.) Anna Goebel
<br />WAS OEn..lIO EYII IN U.S. ......10 rOICIS? IN'OVUNl -HAM!- IUAIJONSHIt - ....llING ...OO'US 11111110' .. n NO. ~." ('0 'O"'{j:}ea"!."o:
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />STATE DEPART~ENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br />A TRUE COpy OF AN ORICINAL RECORD ON FILE WITH THE
<br />DEPARTMENT or HEALTH, BUREAU OF VITAL STATISTICS,
<br />IS THE LECAL DEPOSITORY FOR "!TAL RECORDS.
<br />
<br />J/?,Od~ ~f.,u
<br />DIRECTOR OF VITAL STATISTICS AND ~5SISTANT STATE REGISTRAR
<br />LU,COLN, r~F.nRASKA Is sued I-lilY 4, 1 g79
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