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<br /> PHS-798 (VS}Reu. 4-48. Federa!Security Agencg, Public Health Serviee. (Containing 475 printed tnords}
<br /> I`LO. 18B�THEAUGUSTINECO.GR�KDISLANQ.NEBR. '
<br /> i ?ATt Of t��8g85ttA Filed in the ojJiee of the Register of Deeds the 4 day
<br /> CERT'IF'ICATE OF DEATH i ,/�a Hall � of April 1951 , and recorded in Miscellaneous
<br /> OF I Record No. Q on Pape 209 ��o,•a o o •n'1,
<br /> i
<br /> AGNES SMENTOWSKI � l�egisf�r of Dads
<br /> i
<br /> � Appliu la R.E. Deseription By Depufy.
<br /> „I
<br /> - - - - - - - - - - - - - - - - - - - - - -'- -aiz:- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
<br />�
<br /> STATE OF NEBRASKA °p�'•
<br /> DEPARTMENT OF HEALTH Glenn H. Geddes
<br /> Birih No. 126 snreau oi vitat statiaties S#ate File No.
<br /> 7, p D N . USUA ( ere ecease lrve . mstituUon: rest ence ore a ►sswn).
<br /> a. COUNTY Hall a. ST:1TE Nebr, b. COUNTY Hall
<br /> b,CIT�Y� (If outside corporate limits,write Rurap. c. LENGTH OF ST�Y(in this place) c. CI�Y� ([f outside corporate limits,write RURAL)
<br /> TOWN Grand Island I life TOWN Grand Island
<br /> d. FULL NAME OF (If not in hoapital or institution,�ve street address or Iceation) d. STREET (If rura►,give Iceation)
<br /> '� INS'TITUTIO 421 East 8th St� ADDRESS 421 East 8th St�
<br /> M a. irst) . ( � e) a ( st) 4. OF Month) (llay) (Year)
<br /> � DECEASED
<br /> cT„p.o�Print) Agnes Smentowski ! DEATH Dec. 5. 1949
<br /> 6. SEX 6. COLOR OR RACE 7. MARRIED,NEVER MARRIED, 8. DATE OF BIRTH 8. Age(In yrs. If Under 1 Year /Ii Under 24 Hrs.
<br /> I I WIDOWED,DIVORCED (Specify) I last bitthday) I Mos. I Days I Hours I Min.
<br /> F ina.lp �.rhitP nPvor married Tunp A/1A41 5A 5 J 27
<br /> 70s. USUAL OCCUPtLTION (Give k�nd of work done dunn I tOb. KINll OF BUSINESS OR 11. RTH- ( �ty,town or county)(State or forei n 12_ CITILEN OF WHAT
<br /> most o[working life,evrn if retired) INDUSTRY PLACE country) COUNTRY?
<br /> 8 I 8
<br /> At Home , Grand Island, Nebr. US.
<br /> 13. FATHER'S NAME I 14a. MOTHER'S MAIDEN NAME � 14b. NAME OF HUSBAND OR WIFE
<br /> {
<br /> T�hn SmPnt��ki � Francec Warzenik
<br /> 76. WAS DECEA D EVER IN U.S.ARMED FORCES4 16. SOCIAL SECURITY No. 77. INFOFiMANT'S NAME or Signature&Address
<br /> (Yes,no,or unknown) (If yes,give war or dates of service)
<br /> no � Mrs Clara La.wrence Grand Island Nebr.
<br /> 18. CAUSE OF DEATH In!��ral BstwNn Ons�t
<br /> Entcr only one cause per MEDICAL CERTIFICATION and Wath
<br /> line for(a), (b),and(c) �, DISEASE OR CONDITION
<br /> DIRECTLY LEADING TO DEATH• Asthma bronchial
<br /> •This does not maan th� ANT�CEDENT CAUSES �e�
<br /> mode of dyfnp, such as
<br /> bea�t fsilurs, asthenla,
<br /> �tc. It m�ans the dis- DUE TO (b) -
<br /> sase, inju�y, or compli-
<br /> eation which eaussd Morbid eonditions, if any, plviny
<br /> d�atl�. rlss!o tho abovs cause (a) slA4iny
<br /> !hs und��lyiny caus�last. DUE TO (c) - -
<br /> F1. OTHER SIGNIFICANT CONDITIONS
<br /> Conditions cont�ibutinp io ths dsath but nct
<br /> � ►slsted to 4ba disease o�eortdit(on musirty death.
<br /> 79a. DATE OF OPERA- I 19b. MAJOR FINDINGS OF OPERATION I 20. AUTOPSYY
<br /> TION Yes � No ❑
<br /> 27a. ACCIDENT (Specify) 27b. PLACE QF INJURY (e.g.,in or about home,farm. I 21e. (CITY OR TOWN) (CUUNTY) (STA1'E)
<br /> S[TICIDE I factory,street,oti'ice bldg.,etcJ (If rural area,write RURAL)
<br /> HOMICIDE
<br /> 21d. TIME (Month) (Day) (Year) (Hour) 21�. INJURY OCCURR�D I 211.HOW DID INJURY OCCUR?
<br /> OF While at Work ❑
<br /> INJURY m• Not While at Work �
<br /> 22. 1 hs�eby esrlify 4hat 1 attond�d ths dsc-ssed from , 79 , 40 -, 19 , that I laat s:sw th�
<br /> deceaad alivs on ,19 , and that death oeeur�sd ai _m.,from!he eauses and on!b�dal�stat�d abovs.
<br /> 23a. SIGNAI'URh (Degree or title) 23b. ADDRESS 23c. DATE SIGNED
<br /> J. G. Woodin M D I Grand Island, Nebr. I Dec. 6/49
<br /> 24a. BURIAL,I:REMATION, 24b. DATE 24c. NAME OF CEME'TERY OR CRF.MATORY 24d. ,.00ATION (City,town,or county) (State)
<br /> REMOVAL (Specify)
<br /> Burial I Dec 8/49 I Grand Island Grand Island Nebr.
<br /> DATE RFC'U BY LOCAL REG. REGISTRAR'S SIG ATURE 25. FUNERAL DIRECTOR'S SIGNA7'URE ADDRESS
<br /> Dec. 8/49 ( F. S. White Geddes Funeral Home. Grand Island Nebr ___
<br /> 25. I hereby certify I personally embalmed the body of the deceased named hereon. Irwin Peterson License No.1826
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