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<br /> PHS-798 (VS) ReU. 4-48. Federal Security Agency, Public Health Se�oice. (Confaining 475 printed wordsj
<br /> NO. 188-THEqUGUSTINECO.GNAKDISLpND.NEBq. �
<br /> I TA?g Of' r►S8nA5r�A
<br /> ��rr Filed in fhe o�ce of ihe Reqister of Deeds the 9 day
<br /> CERTIFICATE OF DEATH � �� HSZ.1. of Au ,�St 19 0 , and recorded in Miscellaneous
<br /> . � Record No. Q on Page 2��. Q
<br /> OF �'�G„���a�r/
<br /> ,
<br /> Register oj Deeds-]Q6S�1��
<br /> G�orp;ia H. Sleuman �
<br /> i
<br /> � Applies to R. E. Description By Depuiy.
<br /> - - - - - - - - - - - - - - - - - - - - - -�- -��z:_ nr� ?o s-9- - - - - - - - - - - - - - - - - - - - - - - - - -
<br /> E E AQENCY STATE OF NEBRASgA
<br /> PUBLIC HE���H SERVZCE DEPARTMENT OF HEALTH
<br /> Birth No. 1 su�u of vicar scacisti�e State File No.
<br /> CERTIFICAT F TH
<br /> `' 7. PL C OF D H 2. USUA RE ID N ( ere ecease live . f mstitution: resi ence ore s m�ssion).
<br /> a. COUNTY x�,11, a. ST_1TE Nebr b. COUNTY Ha,ll
<br /> �3;.CI'I'Y (If outside corporate limits,write Rurap. c. LENGTH OF STAY{in this place) c. CITY (If outside corporate limits,write RURAL)
<br /> To°wN Doniphan I 30 yrs T wN Dvniphan -
<br /> d. FULL NAME OF (If not in hospital or institution,give atreet address or location) d. STREET (If rural,give location)
<br /> HOSPITAL OR ADDRESS
<br /> INSTITUTION ��IY16
<br /> DECEASED a• Nirst) . ( � e) c. ast) i 4. OF Month) Way) ear�
<br /> (Typ�o�P�int) Geor�ia H �"IQUm� DEATH July 9� 1950�
<br /> 6. SEX 6. COLOR OR RACE 7. MARRIED,NEVER MARRIED, 8. DATE OF B1RTH 8. Age(In yrs. If Under 1 Year If Under 24 Hrs.
<br /> WIDOWED,DIVORCED (Specify) last birthday) Mos. Da Hou=s I Min.
<br /> F�male I White I Marrisd I Sept 6, 1�7� I 76 10 � � - --
<br /> 10a. USUAL OCCUPATION(G�ve lund of work done dunng 10b. KINll OF BUSINESS OR 11. BIRTH- (City,town or county)(State or foreign 12. CITILEN OF WHAT
<br /> most ot working lite,ev�n if retired) INDUSTRY PLACE unt ) COUNTRY4
<br /> Hausewife ! At Home I ��n�erset, Ta. US •
<br /> 13. FATHER'S NAME { 14a. MOTHER'S MAIDEN NAME 14b. NAMF. OF HUSBAND OR WIFE
<br /> E. L. Harrell I �arah Maria James I Joseph A. Sleuman
<br /> 15. WAS DECEASED EVER IN U.S.ARMED FORCES? 16. SOCIAL SECURITY No. 17. INFORMANT'S NAME or Signature&Address
<br /> (Yes,no,or unknown) I (If yes,give war or dates of service)
<br /> no --- J. A. Sleuman Doni han Nebr.
<br /> 18. CAUSE OF DEATH In!e�val Betw�sn Ons�t
<br /> Enter only one cause per MEDICAL CERTIFICATION and Doath
<br /> line for(a), (b),and(c) �, DISEASE OR CONDITION
<br /> DIRECTLY LEADING TO DEATH' �a� u�astric Carcinoma _ � yr
<br /> •This do�s not mean ths ANT�CEDENT CAUSES
<br /> � meds oi dyfny, sueh as �
<br /> hear4 failure, asthenla, Chronic �iSStiY'�.�i�.$
<br /> �te. IZ m�ans !hs dis- DUE TO (b) --
<br /> ease, inju�y, or eompli-
<br /> catlon which eaus�d Morbid eondittons, if any, yivinp
<br /> d�atb. rise to the abovs oauas(a) statiny
<br /> the unda�lying eauss last. DUE TO (c) ----
<br /> 1-5�-X 11. OTHER SIGNIFICANT CONDITIONS
<br /> Conditions cont�ibutfny to!he dsalh but nct
<br /> �elated to the disease o�oondition eausiny dsatl�.
<br /> 19a. DATE OF OPERA- I 19b. MAJOR FINDINGS OF OYERATION 20. AUTOPSYI
<br /> TION
<br /> Yes ❑ No �
<br /> 21a. ACCIDENT (Specify) 21b. PLACE QF INJURY (e.g.,in or about home,farm. 21e. (CITY OR TOWN) (CUUNTY) (STAT'E)
<br /> SUICIDE I factory,street,ofI'ice bldg.,etc.) (If rural aree,write RURAL)
<br /> HOMICIDE
<br /> r
<br /> 21d. TIME (Month) (Day) (Year) (Hour) ( 21e. INJURY OCCURR�D 27f. HOW DID INJURY OCCUR?
<br /> OF While at Work ❑
<br /> INJURY m. Not While at Work ❑
<br /> 22. 1 h��eby cs�tlfy that 1 att de 4he deesased from� I�1 , 79 Jv, to ��l -, 19_� that I laat s:aw th•
<br /> deeeased alivs on-� 19�51 and tha!death ooeu��sd at�.A-m.,trom ths esusss and o�ll�e dat�stated above.
<br /> 23a. SIGNATURh (Degree or title) I 23b. ADDRESS 23e. llATE SIGNED
<br /> P. 0. Marvel M.D. Giltner Nebr 7-11-50
<br /> 21a. BURIAL,I:REMATI0111, 24b. DATE 24e. NAME OF CEMETSRY OH GH�.MA7'ORY 2�d. ..00ATION (City,town,or county) (State)
<br /> REMOVAL (Sp cify)
<br /> Removal & �urial I July 12�50 I Cedar View Ceme'�erv Doninhan NE.�
<br /> DATE REC'U liY LOCAL REG. REGIS7'RAR'S SIGNATURE 26. FUNERA llIREC,TOR'S SIGNAlURh r ADDR�:SS
<br />� JUL 13 1954 I F. 5. Whit� Geddes Funeral Home arand Is�Ana NAhr_
<br /> TO BE ACCOMPLISHED WHEN BODY IS EMBALMED
<br /> 25. I hereby certify I ~personally embalmed the body of the deeeased named hereon.
<br /> Irwln B. Petersan License 1Vo. 1�26
<br /> THIS CERTIFSE3 THE ABOVE TO BE A TRUE COPY OF AN DRIGINAL CERTIFICATE �N FILE WITH THE STATE DEPART-
<br /> MENT OF HEALTH, BUREAt1 �F VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS,
<br /> f CORP) Frank D. R de r M.D.
<br /> �sE`°'L� DIRE� CT0��0 EA�AND�'A--'�lE��EG�'�AR
<br /> LTNCOLN, NEBRASKA JUL 20 19�j0
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