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<br /> PHS-798 (WS) Rev.4-4&. Federal Securit�}Agenc�, Publie Health Seruiee. (Confaining 475 pcinted a�rardsj
<br /> F1O�. TBB�-TX�E�UGU�STINECO.GRA�NDISLAND.NEBR. � �
<br /> f ?RTE EJf tJ£Sf�AStCA
<br /> F'ifed in the o,�ce aj the Reyistec of Dee�s tfie 26 da�r
<br /> �ER�I�IGATE OF DE��� � � Hall � of Mareh ls 51,and recBrded in 1Kisee[Iancrous
<br /> Record NQ. Q on Page 2Q��l��
<br /> OF �
<br /> �
<br /> r Register of Diteds-�.
<br /> Otto 0. Hettrich �
<br /> � App[ies ta R E.Descrtptioe By �AurU-
<br /> I
<br /> - - - - - - '_ - - - - - - - - - - - - - - -�_ _DlZt_ - - � - _ _ - � - _ - _ � - _ - � _ - - - - - - - - - - - - - -
<br /> STATE OF NEBR�4.S�A
<br /> DEP�R'P11�ENT Ola' HEALTH
<br /> Birth Na. 126 sur�au ot vitar scat�t� Sfate File 1Vo. 50-002885
<br /> . P E OF D H . USUA RESP N ( ere ecea ve . matatution: resi nce ore misswn).
<br /> $. courr� Hall f'� _3�2 a. ST:1TE Nebraska n. courrr�r Hall
<br /> �,CI'PY (If outside wrporate licnits,write RaRat). c. E.ENGTH OF S'£AY(in this place) c. CITY (If outaide carporste limita,write RURAL) ,
<br /> TOWN Grand Island I 2�yrs T��'� Grand Island
<br /> d. FULL NAME OP (If not in hoapital or institution,give street addreas ar}ceation) d. STREET (If rucal,give lceationy
<br /> HOSPITAL OR ADDRESS
<br /> I1�FSTITUTIOIV 1217 West. lst street 121? West_lst Street
<br /> DECEASED °. �rst) . ( e) c. st) I 4. �F Month) < aY) (Year)
<br /> ��rp.,r P��„t� Otto 0. Hettrich f DEATM March 6� 1950
<br /> �
<br /> 6. SE7F 6. COLOR OR RACE T. MARRIED,NEYER MARRfED, 8. DATE OF BIRTH 9. Age(Ia yrs. Ii Under 1 Year If Under 24 Hra.
<br /> WIDOWED,DIVORCED (Specify) last birthday) Mos. Days Hours I Min.
<br /> male I white I widowed I Au� 15, 1�65 I 84 6� 19
<br /> 40a. USUAL OCCUPATION(Gtve kind of work done during I 10b. KFNll OF HUSFNESS OR tt. BT H- (City,tow�n or county}(State or foreign 42. CITILEN OF WHAT
<br /> most of working life,even if retired) INnUSTRY PLACE co�ntry) COUNTFtY?
<br /> Retired Farmer , Farm I Oswe�o, Illinois USA
<br /> 73. FATHER'S NAME 14a. MOTHER'S 113AIBEN NAME 44b. NAME OF HUSBAND OR WIFE
<br /> Tohn Hettrich � unknown I Elizabeth Hettrich
<br /> 4b. WAS DECEASED EYER IN U.S.ARMED FORCES7 16. SOCIAL SECURiTY 1Va i7. tNFORMRNT'S NAME or Signature&Address
<br /> (Yes,no,or unknown) (If yes,give war or dates af service)
<br /> no � none Mrs. Ethel Herrrtt
<br /> 78. CAUSE OF DEATH fn!e�rat B�tv+�tn Ons�t
<br /> Enter only one cause per MEDICAL GERTIFlCATION and D�sth
<br /> line for(a), (b),and(c) �, DISEASE OR CONDITION
<br /> DIRECTLY LEADING TO DEATH• Art rial 7 ai 7S vt"a
<br /> ca> E S.r er�- s --, �
<br /> 'This doss not mean tha ANT�CEDENT CAUSES
<br /> mode ot dyFnp, aueh a•
<br /> beart faiturs, aslbenla, (cerebral)
<br /> �te. It m�s�nt the dis- DUE TO (b) -
<br /> qse,Injury, o� eompll-
<br /> catFon whieh eaused Morbid aonditions, ii any, ylvins
<br /> d�atb. riss to tho above oauas(a) stat[np
<br /> ths und�rlylny eaus�last. DUE TO (c) ---
<br /> 11. OTHER SIGNIFICANT CONDITIONS
<br /> Conditions cont�ibutinp!0 41�e death but nct 5 vr.1.��
<br /> 3384 rslsted to the diseaas o�condi4ion eausins daatb. SBTIl�.lty ��o�
<br /> 7Sa. DATE OF OPERA- I 186. MAJOR FINDINGS OF OPERATION I 20. AUTOPSYI
<br /> TION
<br /> �� ,,,� Yes ❑ No�
<br /> 2ta. ACC.IDENT (Specify) 276. PLACE OF INJURY (e.g.,in or about home,farm. 21e. (CITY OR TUWN) (COUNTY) (STA7'E)
<br /> SUICIDE __ I factory,street,oflic=bldg.,etcJ (It rural avea,write RURAL)
<br /> HOMICIDE __
<br /> 27d. TIME (Month) (Day) _ (Year) (Hour) ( 27�. INNRY QCCURR�ED I 27t. HUW DID INJURY OCCUR2
<br /> OF While at Work Q
<br /> I1IUURY m• Not While at Work ❑ ��
<br /> 22, i heroby esrtify that 1 ait�nd�d !h� d�es:+sed f�om _-j?n , 19I�A-, to Mareh 6, -, 19�_, that 1 las4 saw th•
<br /> deeeassd alivs on rj.t}1 MgTCh , 19�-,and that dsath ooeu��ed a� -m.,i�om th�oauses and on th�dat�s4at�d abor�.
<br /> 23a. SIGNATURr. (Degree or title) 23b. ADDRESS 23e. DATE SICNED
<br /> W, D. McGrath M,`D. I Grand Island�Nebr I 3-12-50
<br /> 24a. BURIAL,I:REMATION, 24b. DATE 24e. NAME OF CEMETERY Oft CR�MA7'ORY 24d. ..00ATIOAI (City,town,or county) (State)
<br /> REMOVAL (Specify) I
<br /> I March 9. 1950 { Rose Hill Ceineter�► PaLaer, Nebraska
<br /> DATE RN'C'll liY LOCAL REG. REGiSTRAR'S SI NATU'RE 25. FUNERAL DIRECTOR'S SIGNA7'URE ADDRESS
<br /> MAR 15 1950 I F. S_ White I Lee E Nicholas Palmer, Nebr.
<br /> 25. I hereby certify I p�rsonally embalmed the bodp of the deceased named hereon Verden E. McIn�y�e::
<br /> License No 1888
<br /> THIS CERTIFIES THE ABOVE TO BE A TRUE COPY OF AN ORIGINAL CERTIFICATE ON FILE WITH THE STATE DEPARTMENT OF HEALTH,
<br /> BUREAU 0� VITAL STATISTIGS, WHICH IS TE� LEGAL DEPOSITORY FOR VITAL RECORDS.
<br /> (SEAL) Frank D. Ryder, M.D.
<br /> DIRECTOR OF HEALTH AND STATE REGISTRAR LINCOLN, NF,BRASKA FEB 13 1951
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