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<br /> PHS-798 (VS) Rev. 4-48. Federal Securitg Agency, Public Health Seruice. (Containing 475 prinfed words}
<br /> NO. 188-THE�UGUSTINE CO.GR11I:D ISLAND,NEBR.
<br /> I TATS OF tJ£88A5KA
<br /> �] ��rr Filed in ihe ojjice of the Reqister of Deeds the �,1, dag
<br /> CERTIFIGATE OF DEATH i r��0° �3.CL of March ls 51 , and recorded in Miscellaneous
<br /> , • � Record No. Q on Page ,��8 � /�� n
<br /> OF �,,,u,�, yY�
<br /> �
<br /> � Register of Deeds-�t3�SL�1,i�X
<br /> Mary Elizabeth Eberl i
<br /> � Applies to R. E. Description By Deputy.
<br /> �
<br /> - - - - - - - - - - - - - - - - - - - - - -'- -viz:- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
<br /> STATE OF NEBRASKA
<br /> DEPARTMENT OF HEALTH
<br /> Birth No. 1�� suresu oi vital stat�at�cs State File Na
<br /> 1. PL CE OF EA N 2. USUAL RE ID N ( ere ecease rve . f mstitut�on: resi ence e ore a m�ss►ou).
<br /> a. courr�rx ��l ���, a. ST:1TE �@}�j'a,8]L8 b. COUNTY Ha7.l
<br /> y, CIT�Y� (If outside corporate hmits,wnte Rurap. I c. LENGTH OF STAY(in thia place) c. CI�Y� (If outside corporate limits,write RURAL)
<br /> TOWN �.rand Island TOWN Grand Island
<br /> d. FULL NAME OF (If not in hospttal or�nsUtutton,give street addresa or IocaUon) d. STREET (If rural,�ve location)
<br /> HOSPITAL OR ADDRESS
<br /> INSTITUTION 1Q02 West John �ti� �Q�2 ��$ti J��1ri s�i
<br /> � p a. Nirst) . (M► e) c. ( ast) � 4. OF Month) ( ay) ear/
<br /> � DECEASED DEATH
<br /> cT,,p.o�Print) M Elizabeth Eberl 9 �0 50
<br /> 6. SEX 6. COLO OR RACE T. MARRIEU,NEVER MARRIED, 8. DATE OF BIRTH 8. Age(In yrs. If Under 1 Year If Under 24 Hrs.
<br /> WIDOWED,DIVORCED (Specify) last birthday) Mos. Days Hours Min.
<br /> F'emale I Wh�t� I Never Marri�d I 1-�-18?3 I 7? � �
<br /> tOs. USUAL OCCUPATION (Give Innd of work done dunng I 10b. KINll OF BUSINEJS OR 77. BIRTH- (City,town or county)(State or foreign 12, CITI'LEN OF WHAT
<br /> most of working life,even it retired) INDUSTRY PLACE country) ' COUNTRY7
<br />� HousekeepEr , Home I Grand Tsla.rid. �tebr. �. S. A.
<br /> 13. FATHER'S NAME 14a. MOTHER'S MAIDEN NAME 1 b. NAME OF HUSBAND OR WfFE
<br /> Geor e r I Mar Rothmer I None
<br /> 15. WAS DE EASED EVER IN U.S.ARMED FORCESY 16. SOCIAL SECURITY No. 17. INFORMANT'S NAME or Signature&Address
<br /> (Ye�sT,no,or unknown) I (If yes,giv�TwQar or datea of service)
<br /> iY 0 Ev
<br />� 18. CAUSE OF DEATH MEDICAL CERTIFICATION In•.s�val Bstws�n Ons�4
<br /> Entcr oniy one cause per and Dsath
<br /> line for(a), (b),and(c) �, DISEASE OR CONDITION
<br /> DIRECTLY LEADING TO DEATH• �e� Emboliam _
<br /> •This doss not maan 4h• ANT�CEDENT CAUSES
<br /> mode oT dyinp, sueh as
<br /> heart iailu��, asthsnia, Arteriosclerosis 10 yr�
<br /> �te. It m�ans ths dis- DUE TO (b) •
<br /> I sass, fnju�y, o� compll-
<br /> 2ation whleh caused Mo�bid eonditlons, If any, piriny
<br /> d�sth. riss to the abovs eauss(a) statfny
<br />- . �� � � � � the unds�lylny cawe last. DUE TO (c) -------
<br /> 11. OTHER SIGNIFICANT CONDITIONS
<br />� - 1�,C QO Conditiona cont�ibutinp to the dsath bu!nct � � - �
<br /> `'+J rslated to the dis�ase o�eondilion causinq d�ath.
<br /> 19a. DATE OF OPERA- I 19b. MAJOR FINDINGS OF OYERATION I 20. AUTOPSY7
<br /> TION
<br /> Yes p No i0
<br /> 21a. ACC[DENT (Specify) 21b. PLACE OF INJURY (e.g.,in or about home,farm. I 21c. (CITY OR TOWN) (COUNTY) (STA7'E)
<br /> SUICIDE I factory,street,olTice bldg.,etc.) (If rural area,write RURAL)
<br /> HOMICIDE
<br /> 21d. TOfF E (Month) (Day) (Year) (Hour) I 21s. INJURY OCCURR�D I 21f. HOW DID INJURY OCCUR?
<br /> While at Work �
<br /> INJURY m• Not While at Work ❑ `'�' x' "
<br /> 22. 1 hsreby osrtity lhat 1 att� d• e dsesased from_� , 1�to.�gP=f% �tJ -, 19��, tMat 1-1ast s:�w th•
<br /> deeeased s�ive on �Qp� �� ,.19 , and tha!daath ooeu�rsd a �.sn.,i�om 41��causes and on tF�s date stated above.
<br /> 23a. SIGNATURh (Degree or title) 23b. ADDRESS 23c. llATE SIGNED
<br /> E. E ��kel D, O I arand Island ( 9-.2?-58
<br /> I 24a. BURIAL,CRb:MATION, 24b. DATE 24e. NAME OF CfiME TaRY OH CH�MATORY 24d. ..00ATION (City,town,or county) (State)
<br /> REMOVAL (Specify) I 9-22_5� I Grand Island CEmeter� I Grand Island �a
<br /> BuriA� .. .
<br /> DATE RF:C'U 13Y LOCA G. . N L DIRECTOR'S SIGNAlURh A �DRESS
<br /> SEP 29 1954 ( F'. S. White -
<br /> 2S . I hereby certify � personally emba.lmed �he body of the decea�ed named hereon
<br /> James D.'°,�,ivingston. License No. 1835
<br /> THIS CER.�IFSES THE ABQ��fE TO BE A �RUE COPY OF AN ORIaZNAL �ERTIFICAT� �N FILE WITH �HE STAT�
<br /> DEPARTMENT OF HEALTH, BtJREAU OF 1TITAL STATISTICS, WHICH IS �HE LEGAL DEPOSITORY FOR VITAL R�GORD�.
<br /> (SE.AL)
<br /> Frank ]J. .R,,,�der M. D.
<br /> , a�� ,
<br /> DIREC�OA OF HL�A��'$ AiVD �TA�"� �tEC�I�3TRA..�.
<br /> LIPJCOLN, NEBRASKA MAR 28 19 1
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