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<br />86-101509
<br />Bureau of Vital 1Ealisfiel
<br />CERTIFICATE OF DEATH- JtI;_'> •Nn 1. rl,rNR
<br />OKUS>W --NAME r,nr erlllf I•sr ful DATE OF DEATH , rarl., D•r, n•.,
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<br />uwpf• + ny !tiM1. a a.r ? DATE OF bKIH ,ra»I., .•.- iCOLINTV OF DEATH -
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<br />CRY, TOWN. OR LOCATION OF DEATH +.•s+w cH! ,r•n 1,OSPITAL W OTHER 9471TUTION –NAME +�. >WI ,r tll.lt- GWI {IY,f •nr1 «wNH.1
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<br />CITIZEN OF WHAT COUNTRY �MARMI). NEVER MARRIED, ;SURVIVING SPOUSE , n w,H, G_ .urof1. •rr 1
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<br />SOCIAL WCLMITY MIMRER uSU�t OCCLMA7gN ,a.t aw o. w•a wN w..r.c .'on o.- 1cNp bf EUSMESS OR NOUSnr
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<br />RESIDENCE -STARE COUNTY lCRT, TOWN, OR IOCAT,ON wsrr cm uwrtf STREET AND NUMbEb
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<br />FATNER –NAME H1sr - rYIN I.. MOTTIER– MAIDEN NAME re•fl r:Ob1 YIT
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<br />I WAS DECEASED EVER IN U.S. AWED FOKES7 INFOfY,SANT –NAME_ REWIONSHIP– MAIUN,. ADDRESS :,Hen o• • 1. »o , C." 61�SBNI1 {a.w, tlr+
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<br />P. I DEATH WAS CAUSED by JENTfR ON(T ONE CAUSE PEE tINE FOR tal, ibJ. -NO icll
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<br />PART 1 OTNE1 SIGNIICAHT COHOITIONS CO —TIONS CONTMNnMG TO DEATH SUr HOT IEIA7ED
<br />'ART N1 If fYYLE. WAS THERE A AUTOPSY IF Yf5 wt•1 1,.DrwGf cOw-
<br />To C"SI GMN M IAIf NO
<br />PREGNANC7 M IHE PAST S M.."'s, n{ ar »01 NOt.eD 1w Dllrtrw+.G c•v>,
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<br />ACCIDENT. SUICIDE, HOANCTDE. DA IN Y ,.o.r., p.., .e•n
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<br />INJURY AT WORK
<br />PLACE OF INJURY., «orf, ryr, nYn, I.0oD.,
<br />LOCATION 131■fIT W LLp. r0 Ub O. IOww, Ma,
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<br />CERTIFICATION- MEDICAL EXAMINER OR C it Or 1wt ML1{ Or I.I .ow or p.r. t., OKIpM wy rIOHOOKfO b.p
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<br />FLOW. LEEMAT gN, REMOVAL C MUM OR C O Y –NAME 1
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<br />Tf. �emoual 7E&ate . ,qna•tofnical `3oaad
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<br />DAR[ I rorl., a1, nu, FUNERAL NOME –NAME AND ADM $$ ,HI,+ o• . r.p »D , c r. O• +ow» a .H
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<br />th"I IER- SIGNATURE R OCEN E NO.
<br />REGISTRAR- SK.NAtLW "It ucnVeo br IOCAt 1tGRTRAI
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />STATE DEPARTMENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br />A TRUE COPY OF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH
<br />IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DIRECTOR OF VITAL STATISTICS AND_ ASSISTANT STATE REGISTRAR
<br />LINCOLN,NEBRASKA Issued December 13, 1977
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<br />REGORDERS MEMO.'
<br />Reg otc�-
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