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<br /> � �� � � f� � �. � � � � � � �. ��
<br /> P�IS-798 (VS) Rev. 4-48. Federal Security Agency, Public Health Seruice. (Coniaining 475 prinfed u�ordsj
<br /> NO. IBB-TXEAUGUSTINECO.GRANDISLFND.NEBR. - -
<br /> 1
<br /> I ?A?E O£ tJS98A5KA
<br /> �,,rr Filed in the o�ce of fhe Register of Deeds the z3 day
<br /> CERTIFICATE OF DEATH � �'00 HaI�- of December ls 50 ,and recorded in Miscellaneous
<br /> oF { Record No. Q on Page 205 .�' /l%�S��M•
<br /> � �� ��
<br /> Register of Deeds-�nGlit}j7�.
<br /> Maria Hameloth �
<br /> i
<br /> � Applics to R. E. Description By Depuiy.
<br /> I
<br /> - - - - - - - - - - - - - - - - - - - �'- -oiz:- - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - -
<br /> STATE OF NEBRASBA
<br /> DEPARTMENT OF HEALTH
<br /> Birth No. � �h Bw�u ot vira�srat�ti� State File No.
<br /> 1. PLA E"OF N 2. USUA RE51D NCE (W ere ecease rve . matatuUon: resi ence ore a miss�on).
<br /> / . a. COUNTY H�.11 a. ST_1TE N c b. COUNTY Ha� �
<br /> rr ehr�� k�
<br /> �•CI'PY (If outside corporate limits,write Ruraf). c. LENGTH OF STAY(in this plaee). c. CITY (If outs� e corporate'�uni a,wnte RURAL)
<br /> TOWN Grand Island I �j� TOWN Grand Island
<br /> d. FULL NAME OF (If not in hospital or institution,give street addresa or location) d. STREET (If rural,give lceation) '
<br /> HOSPITAL OR ADDRESS
<br /> INSTITUTION �
<br /> F�`l6 Nn. jfalntlt rt� <1Talni�t
<br /> �. ME F a. Hirst) . (Mia� c. ( st) 4. Month) ( ay) (Year�
<br /> DECEASED OF
<br /> (Typ�o�P��nt� Maria Hameloth � DEATH Oc.t. 1}� , 1�50
<br /> -r
<br /> 6. SEX 6. COLOR OIi RACE 7. MARRIED,NEVER MARRIED, 8. DATE OF BIRTH 8. Age(In yrs. It Under 1 Year If Under 24 Hra.
<br /> I I WIDOWED,DIVORCED (Specify) I I last birthday) I Mos. I Days I Hours I Min.
<br /> � a � W A
<br /> t0a. USUAL OCCUPATION (Give kind of work done dunng I 70b. KINll OF SINESS OR I 11. B - Crty,town or county)(S ate or fore�gn I 12. CITILEN OF WHAT
<br /> most of working life,even if retired) INDUSTRY PLACE country) COUNTRY?
<br /> No�a�Pwi fe ,
<br /> 13. FATHER'S NA E 14a. MOT E S MAIDEN NAME • SBAND OR WIFE
<br /> Schroeder I No Record �7ohn H mPl n .h
<br /> 16. WAS DECEASED EVER IN U.S.ARMED FORCESI 76. SOCIAL SECURITY No. 17. INFORMANT'S NAME or Signature&Address
<br /> (Ycs,no,or unknown) I (If yes,�ve war or datea of service) I
<br /> Grand Island, Nebr.
<br /> 18. CAUSE OF DEATH Ire!erral B�twNn Ons�t
<br /> Enter only one cause per MEOICAL CERTIFICATION and Dsath
<br /> line for(a), (b),and(c) �, DISEASE OR CONDITION
<br /> DIRECTLY LEADING TO DEATH' hPart 'e�?il urP & p� C3 �P
<br /> ca�
<br /> •Tbis doss not mean th� ANT�CEDENT CAUSES
<br /> mods oT dyinp, such as
<br /> heart failur�, asthsnla,
<br /> �te. It msens ths dis- DUE TO (b) -
<br /> ease, injury, or eompli-
<br /> cation whicl� eaused Mo�bid eonditions, if any, plvinp
<br /> d�atb. rise to the above eauss(a) atatinp
<br />. the unds�lyinp eauas last. DUE TO (c) ---
<br /> I1. OTHER SIGNIFICANT CONDITIONS
<br /> Conditions cont�ibutiny to ths dsalh but nct
<br /> �sla4sd 4o ths disease o�oondltion eausinq d�atF�.
<br /> 19a. DATE OF OPERA- I 196. MAJOR FINDINGS OF OYERATION I 20. AUTOPSY`I
<br /> TION
<br /> Yes 0 No [�
<br /> 27a. ACCIDENT (Specify) 276. PLACE Ol�' dNJURY (e.g.,in or about home,farm. I 21a (CITY OR TOWN) (COUNTY) (STA1'E)
<br /> SIJICIDE I factory,street,otTice bldg.,ete.) (If rural area,write RURAL)
<br /> HOMICIDE
<br /> 27d. TIME (Month) (Day) (Year) (Hour) I 21�. INJURY OCCURR�D I 21f. HOW DID INJURY OCCUR7
<br /> OF While at Work �
<br /> INJURY m• Not While at Work ❑
<br /> 22. I hsreby e��tity tbat 1 atl�nd�d ths decsas�d f�om , 79 to ._, 78 , !ba! 1 las4 a:aw !h�
<br /> doceased][�/s on �r'�- �� 19�� and tha!dsath oeeu��sd atl (1 t al�,�n.,f�om ths oauses and on th�dals atat�d above.
<br /> 23a. SIGNA7'URh (Degree or title) l 23b. ADDRESS { 23c. DATE SiGNED
<br /> g��+ rnng I �rand I�� an�, N r� I ln./lFi/��
<br /> 24a. BURIAL,l:R�OT 011T� � �p2�6v�ATE �- --3ZerNAME OF CEMETERY OH GR�.MAIOHY i ��tf. ..00ATION (City,town,or county) (S a e�-
<br /> REMOVAL (Specify)
<br /> Btarial I'10-1�-50 I Grand I�land r=r nr1 Tsland, rr
<br /> DATE REC'll liY LOCAL REG. REGISTRAR'S SI NATURE 25. FUNERAL DIRECTOR'S SIGNA7'U�E �.�5
<br /> Oct 19 1950 I F. S. White I _
<br /> 25. I here'oy certify I personally embalmed the body of the deceased named hereon. ���5 � n����n
<br /> THIS CERTIFIES TN:E ABOVE TO BE A TRUE COPY OF AN ORIGINAL CERTIFICATE ON FILE WITH THE STATE
<br /> DEPARTMENT OF HF�ALTH, BUREAU OF VITAL STATISTICS, ��Jf�iICH IS THE LEGAL DEPOSITORY FOR VITAL
<br /> RECORDS.
<br /> ( SEAL) Frank D. R der M. D.
<br /> DIRECTOR OF D A E S
<br /> LINCOLN, NEDRASKA DEC 5 1950
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