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° . onfAUA v UCi n�aU t, tIF 1: �tt :t� tc•rni�. <br /> R!V 1� . T . . - . <br /> i �?�� � y��1)rvjNion oC��'ttal�tetiAiicx <br /> GER7IFICATE OF` DEATH A.-�.� .�� <br /> T1f►E. OR �NNT M . � _ . ��:r ,�.•x„Y- :._a...�..:�- <br /> /f�MANINT �NK - �� c"�°" � - � �� -� � -- <br /> OECEASED—NAME �u+t��� '_ �, r� -�"�rowe ,,, ,:,�}+' . -'�����t SEIf-- DA Of DE TM���+0«M�e�(-, ���� <br /> •ien�wo.ta '�t r i �;�s. =��i'OLlII� r <br /> �. " , . . a ,. • � . ��jM1, � <br /> R�CE�.�ne,Nea�o.AY��I(�N INOI�M� A(�iE�I�O " V����^���� u«oe��o�r�=� OAfE Ot./IR1H_t«o«�w,e�e�r <br /> I(��� \ .. ra��'.,'��. COVNTyfiOf, AiH - <br /> ',� l�C. 1{►ICl/t 1 - •I�INO�t 11'IA�31 MOl. . '.�OAt3 MOY\S MM,�,a J� v,_:l�aay�{� ,.. �: . . '�. <br /> �', /� � ' \IVllit@ S. �-^� - , . � � . ' �:� <br /> 32 H ;�:..; s� �=� j �� ►. <br /> � CITY,TOM�N,OR IOCAtION Of DEATM n+fro�tm urn�, Mp5►tT�t OR pTHER RlSTI)UiION—w,u�E�x�.o���enrrn,GM frq�t�Mo Ny.y��� <br /> i , ` -� irecm res o�no <br /> ',� ,y�,^Nca � r_;� � <br /> i V ; : `_ �. ,� � <br /> n Omehe ,� . �` <br /> es�� ��. 115-No. "33rd�St` .�- ���.�,�����_��• <br /> � STATE Of 61RiN i v Nor iN u,s.�„..•r�GITIZEN Of WHAT COUNTRY MARRIED,NEVER MARRIED # 3 SURvrv�G S►OUSE rN rn�t ant wiotN w�w t <br /> cou..m� WIDOwED.DIVORCED�sietwr� 'V ;;;� � '`�":'�, � 'r � . 4- <br /> vsu.��e�awce ` . '-r �, a�„ �:� <br /> �lIel�r_a,ska , ,�- +� . i� _.�..:��� .� ��,.. eano���Siu�h <br /> M'Mt�e oK��f/0 `.�+-� <br /> uveo. o oe�m SOCUt SEGURI(Y NUMSER � USWt OCCU�ATION�am cr.o or wou pp,�ewi«a rov or KWD Of lUSINESS OR 1 STRY,�,� �-� .r.- ,u <br /> occu�uo�. .�w�wo�ne,m«n�rn�eo� .. � � �- f,��.-.t.� �,�,�'�� { k � <br /> �n�.nu+�a+.cn�e tt � � �I.. - .� -. . ;-��� �.:.�. �1,. 4:^ ,y..�� 1 ��,. <br /> ni�oe»ce�ero�e In �<a � n�{CQ x* _� <br /> �ewsfar. RESIDENCE—SMTE � COUNT� � CITY,TOWN,OR LOCATION � s a.sroi cm�rin S I1 D HPU7a6E� <br /> �� i srecrr.ref o��o i r., $ P�, � x ';�'4+��` . <br /> '� ��.Nebraska ��► Dou las � �k. Omaha ��� =` i"kr: F ' ` � <br /> s ��. 5-R `=33r = � x..< <br /> fAiMER—NA�+E rnfr M�oote:.; � ��St MOTHER—MAIDENNAMf - -�mft . ,<:,rroM1•4��'�,.�� a.��ult�>.. �^ <br /> � �s. eff Glover � �s� : ' Ma . Eva : NfcKim �: � <br /> , . ��-wAS DECEASED EVER IN U.S.ARMED fORCESi 1NFORINANT—NAME—REIAiIONSNI►—µA��ADORESS lsttett o��ro.rM Cirt o�+o sr�r�,=w�� � <br /> . (Y�6 M.O�Y��Mv�I pl ry�,piw war end deN��1 Nnk�) . - �� _ ; � <br /> a W r �,. 8423 <br /> � ►A�i 1. pE�iH W�S C�USED�Y: - �fNlElt ONLY ONE C�USE KR IMJE FW1 fo1.(6I.AND(an ., - _ � �rnOu.ut v� �ry>.,_��'.� <br /> U o..wou�e c��se <br /> ��weir o�t���.a N.rw <br /> '�� <br /> yi�3 ��� Severe coronary atheroaclerosis � .-;j <br /> . ♦ A M t U . . �� � . . , .. '� <br /> COMOITIOM3, 1� �M, 1(I � , ' , ' � <br /> 1YNICM GAYI �If!10 I �e� - ' . � � � <br /> . IYYfDI�If C�USI 101, i DY!IO.q AS�CONSlOVlMCt O�: ' .� <br /> SI�IIM6 1M� YMOf�• <br /> 111M6 C�Y31 1�1I � . ` � . �� <br /> (�� <br /> � Mti 11. OiMF�SIGN111CANT CONDIiIpN3:COHDITIOMS CONT�I�UTIN6 fOOEAiN Wt HOi�EUiED �AB III.It fEMAl4 MUS TNE�f A AUTpSt� ,�If YFS w��e nwoi�pf CM�-;'%. <br /> i0 CAVSF GIVfN IN�A�i N�) , � ►f(GNANCr IN iM[/ASi 7 MONiMS� ��fS q wd���- f�0��lD Iw DtTl�rlrlMO 4Vf���� <br /> „e�.�� Yes �,� <br /> _AEu_ e foca broncho neumonia .�so ►.00 ,�ye$ F� <br /> ACCIOENT,SU�CIDE,HOMICIDE, DATE INIURY �row�w,p��,�e��� M UR NOW INIURY OCCURRED ����MAN�i 01 IM)y���M���1 1 O����1 II�rt�r��� <br /> OR UNOETE�MnaEO�via�.r � . �- � ' „ . -�":-,�, <br /> � � .. 7M M. !M . . • � �� .:,� <br /> INJURY AT WpRK ►UCE OF INIURY•��o.+[,.•�.,,frner,r.cru•, tOCATIpN �fotn O��.�.o.wo.,c�n O�rorw,�ir�tt� � <br /> I SrlCln 1!S 01 r�01 O�rICI�IOG.,lIC. ISrK�nl ' � � . . . � . - ' _ <br /> 70� }CI ' ' 70j . . . _. ' ..-."' „ .-. :_.. :.. . . . �n <br /> � CERTIfIUT10N— .�wnw o.• r�u .�oMm o�r rw AND 4�/fAM MW/M����IV�QN �oro/o�o wi v�n►mt o[�rh octuetto u n�� ��'��' <br /> rNrs�ci�w: Tp ra+n� e�r re.� �oo�,�m�w�m:- � ►ua.o�n�t .=.� <br /> MOV�� . O�R.�MD,IO M�k31',� <br /> 1��l[p0t0 Mf .. -. - . p�r�tnOMlfOGf.OV[..�-'rt <br /> fl• oece•seo rwr � 71Y flt � 711. 71r M.�O tet Uvuq�st�tes.-.-. <br /> . CERTIFIUTION—MEDKAI�EllAM�NfR OR CORONE�:Ow Th!��f�f Ot�w! '»py�O�p�M ��t oeeeaw�w�s r�o�.p/�eeo oe.o � <br /> ft���H�I�OM 01 M!W01�wD/O�Ih!IwvtfTqAlqw,Ip��O��NION, " I�pNTM - t y�O�/��(�' (] ��� �. �. Np�� � t <br /> Dl�IM OCCY��lO OM M!D�I!�MD DVf 10 M!UVSIISI S��f�D. DP.CP+TRUe` L7 �7��� � �� <br /> rT. Fd: 1:47 P M.rn � 1•47 P M:; ' <br /> CFtiiHER—N,�ME mre o�ruHn � SIGNATURE oee�e�w nru ATE SIGNED�.a+m,o.���u� <br /> ��. B.Y.Roffman-M`.D. •De .Cor. Ph s. „� s Blaine Y. Roffiman M.D. ,�1-14-75' <br /> M.eIUNG ADORESS—CfRt1flER s�nn o��.r.o.no. un q�oww . . y�.h =,� , <br /> r� 10 Doc ors uildin Omaha ' Nebraska 68131 <br /> � lURIAI,CREAMTpN,REMOyAI CEMEiERY OR CREMATORY—NAME � LOCAiION � C�n O��Ow�r�. � -.ft�ry . - <br /> 1 S�fC1/'/1 - _ � <br /> i <br /> N� 11► <br /> f1�. <br /> � DATE �Np.�rn,Oo,q��� _ FVNERAI NOME—NAM AND ADORfSS �intlr p��,�,0.r�0.,CIi�O��OMM�1��f��j1►1 - ����� <br /> 7N f3�. -'"� <br /> � EM! R—S GNAI E.�U Sf NO.� ��� REG — . � owr[�ettnco n ioewi�eO�ir���-. '• <br /> y, <br /> zs ��:a= ,. .` 30� ; � . - �w . `JAN 151975 : � ' <br /> �- � <br /> � �� ^� � � a; <br /> �~ +t' �..� .•'"'.�,,* •...E. . _ .______ _._,�. _. `... � . .: <br /> r' t� § • �f'��,� . . � ' �:�,k,°�.' .r <br /> �`�� .�r � ,����I� }:- .. . .� ,r-at '3 �I.; :in.' 0 3 �,�� <br /> , �fo r c � - .. . � �:� ��_ <br /> ,L�'`� �'`�•J ! f r'�atfj ' , Page. _tz�'. { �� <br /> �� � 'ti ��.', , � , �� . . _ . Jeam, isher, Regis�er,of Deeds„ s- <br /> } -?i}�� R-SY „c a` <br /> ' ;'d :.� " ,�,��'<� _� _ .Ha�11 Coiinty, Netiraska �'� <br /> . {: , x ,:.. <br /> j •: �,� �� ..� ..�:.: �;�, �. , . .,. � . <br /> I h�e�y,c��t�fty�th�t�t�e•;abave is a true and correct copy of 'the Certificate � �� '- <br /> of D�atit•;� recorded,�:il y��he'' C�ity of Omaha� :County of Douglas� "State of Nebraska.� 6�� <br /> �I . :'g��� '�.'.� •• .� .d. . ... � . - " .3`r ,�nf c.w �,a� <br /> f,, . A�. ��11���i'�.�� .✓�sr', . . . � .� ._. _ ' � h ��. . <br /> Dated this_+�� �� 14th � day of �Februarv � �,1975 � > ��'��'� <br /> !I� . - <br /> �c 2 �� <br /> .a. b"<:t _�t ...f"' �� ���o- : 4� � <br /> � �- �a* �' »w�.,-��' .s� y �,�- <br /> . , <br /> a : . � .: : <br /> �i /` �'��� �:���" ��. <br /> � rQT 'r � .. . , - � Y+'y.`Sa'�s', +�` r. <br /> /� Y <br /> P J � .� F i 1, � .� : <br /> . " :�. .C�" ��3 .. y���{ �� .� : <br /> ,fy �.✓� "u'�''" _ BYI'81" ,r��i�^� ��.�cY t c <br /> . . � - .. , . =k _� �� :.i� <br /> , � y•, <br /> ff . <br /> x- n <br /> � <br /> /�;� _� � �-x # '�-t�� ,�` s�/� <br /> L/f} ���ly' :' '�}� a?, '�f� �'�' �,s r/} <br /> �. �� ./����t'� �I„ ,�1_/u-ff''r�..ea�•-:'x'7 Xs .QsK.�"�- I� <br />