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<br /> ���� � 9 ��� PHS-798 (VS) Rev. 4-48. Federal Security Agency, Public Health Seruice. (Containiag 475 prinfed words}
<br /> NO. 168-THEAUGUSTINECO.GR�Ii015LAND.NEBR. - �
<br /> I �tA?E Of iJ£88A5KA Filed in the o�ce of the Register of Deeds ihe 22 dall
<br /> CERTIFICATE OF DEATH � ,/�°"o� Hall � of April 1951 , and recorded in Miscellaneous
<br /> � Record No. Q on Page 210
<br /> OF � ' ��,H,,v �o�
<br /> Register of Deeds
<br /> t
<br /> Peter Andrew Pedersen �
<br /> � App[ies to R. E. Description By Deput�.
<br /> i
<br /> Lot 6, i3lock 9, Voitles.
<br /> - - - - - - - - - - - - - - - - - - - - - -�- -DIZ:_ - - - - - - - - - - - - _ _ _ - - - - - - - - - - - - - - - - -
<br /> STATE OF NEBRASKA
<br /> DEPARTMENT OF HEALTH
<br /> Birth No. 12�' sureau ot vita2 stacisncs State File No.
<br /> 7. PLACE OF D TH 2. USUAI E D N E (W ere ecease l�ve . If institution: resi ence e ore a m�ssion).
<br /> a. COUNTY Howard P-362 a. ST.1TE Nebraska b. COUNTY Howard
<br /> . CI"OY� (If outside corporate limits,write Ruraq. c. LENGTH OF STAY(in this place) c. CI�Y� (If outside corporate limits,write RURAL)
<br /> TOWN St. Paul I 1 week TOWN Dannebrog
<br /> d. FULL NAME OF (If not in hoapital or institution,�ve street address or location) d. ADDR SS (If rural,give lceation)
<br /> HOSPITAL OR
<br /> I INSTITUTION Memorial Hos�ital
<br /> �. AME O a. rust) . ( i e) c. ( ast) � 4. D (Month) ( ay) (Year�
<br /> DECEASED OF
<br /> DEATH T
<br /> cTVp.o�P�in!) Peter Andrew Pedersen
<br /> 6. SEX 6. COLOR OR RACE T. ARRIED,NEVER MARRIED, S. DATE OF BIRTH 9. Age (In yrs. It Under 1 Year If Under 24 Hrs.
<br /> WIDOWED,DIVORCED (Specify) last birthday) Mos. Days Hours I Min.
<br /> Male I White I Married iulv 6, 1887 63 �
<br /> 10a. USUAL OCCUPATION (Grve k�nd of work done dunng 70b. KINll OF BUSINE�S OR I 7 . B TH- (City,town or county)(State or foreign l 12. CITILEN OF WHAT
<br /> most of working life,even if retired) I INDUSTRY PLACE country) I COUNTRY?
<br /> Retired Farmer � Dannebrog, Nebr_ U_S_A_
<br /> 73. FATHER'S NAME 14s. MOTHER'S MAIDEN NAME 14b. NAME OF HUSBAND OR WIFh
<br /> Rasmus PederaPn I Karen LauritSen � �ar�lin� PedPrtPn
<br /> 75. WAS DECEASED EVER IN U.S.ARMED FORCESY 16. SOCIAL SECURITY No. 1T. INFORMANT'S I�AME or Signature&Addresa
<br /> (Ycs,no,or unknown) I (If yes,give war or dates of service)
<br /> 18, CAUSE OF DEATH MEDICAL CERTIFICATION In!erval BeLw��n Ons�t
<br /> Enter only one cause per and Dsath
<br /> line for(a). (b),and (c) �, DISEASE OR CONDITION
<br /> DIRECTLY LEADING TO DEATH• C rdi u frebrill oti on _].Q min�
<br /> (a)
<br /> •Thls do�s not mean th• ANT�CEDENT CAUSES
<br /> mods oi dyinp, auch as
<br /> heart Tailur�, asthsnla,
<br /> �te. It meyn� the dis- DUE TO (b)z T'P.V7 At1S fl ntter �d cardi ac 1(L�rc�
<br /> sase, 1nju�y, o�compll-
<br /> eation wFich eaused Nlo�bid eonditions, if any, pivinp enlargement
<br /> d�ath. rise to the abovs cauae (a)slatinp
<br /> ths unds�lyiny causs Iast. DUE TO (c) V(1�Vll�AY' (jP.fP.CYS ___1�VTS
<br /> I1. OTHER SIGNIFICANT CONDITIONS also has �Ce3.il 170t read)
<br /> Conditions cont�ibutinp!o the deslh but nct
<br /> �slated to 4he disease o�eondltion causiny deatF�. � mn_
<br /> 18a. DATE OF OPERA- I 19b. MAJOR FINDINGS OF OYERATION I 20. AUTO Y7
<br /> TI ON
<br /> Yes Q No ❑
<br /> 21a. ACC[DENT (Specify) I 27b. PLACE OF INJURY (e.g.,in or abaut home,farm. I 21e. (CITY OR TUWN) (CUUNTY) (STA1'E)
<br /> SUICIDE factory,street,oII'ice bldg.,etc.) (If rural area,write RURAL)
<br /> HOMICIDE
<br /> 27d. TIME (Month) (Day) (Year) (Hour) I 21e. INJURY OCCURR�ED I 27f. HOW DID INJURY OCCURT -^�
<br /> OF While at Work 0
<br /> INJURY m• Not While at Work ❑
<br /> 22. 1 hereby c��tlTy tha! 1 atlend�d th• deceased f�om_�-�4'? , 19 , 40 1�--5 -, 79'1�_, that 1 las!s:sw th•
<br />, dseeased aUvs on, ��-a 19s�_,and lhat dealh oecurred at 7•�(1 A�re„from tb�causes and on tbs date stat�d abovs.
<br />'I 23a. SIGNAI'URh (Degree or title) I 23b. ADDRESS I 23c. DATE SIGNED
<br />� R.W. Harr�sh M D St. Paul_ Nebr_ 11_R_5�
<br /> 24a. BURIAL,CREMATION, 24b. DATE 24c. NAME OF CEMETERY OFt GFt�ATORY 24d. ..00ATION (City,town,or county) (State)
<br /> REMOVAL (Specify)
<br /> Burial l 11/fi-50 I Oak I�-idge Cemeter� nannPhrn�� NPhr�
<br /> DATE RF:C'll liY LOCAL REG. REGISI'RAR'S SIGNATURE 26. FU ERAL DIRECTUR'S SIGNATURE ADDRESS
<br /> 11-�6-50 ( Ravmond A_ Fnrhes _�cnhsen Mnrti�ar� llannPhrn�s,? Nphr,
<br /> 25. I hereby certify I persmnally embalmed the body of the deceased named hereon.
<br /> James P. Jacobsen License ro 1795
<br /> THIS CFRTIFIES THE AI30�'E TO I�E A TRiTE COPY Or Al� ORIGII�AL CERTIFICATE ON FIL� WITH TH� STATE DEPARTMENT dF I-�ALTH,
<br /> I3URF;AU OF VITAL STATISTICS, WFIICH IS THE LFCJAL DFPOSITORY FOR VITAL RECORDS.
<br /> (SFAL) I'rank D. Ryder M. D.
<br /> DIRECTOR OF HFALTH AND STATE REGISTRAR
<br /> LINCOLN, NEI3RASKA ,jAN 22, 1951
<br /> Filed for record this 22 day of April 1951, at lp;l5 o�clock A.t�.
<br /> ���� ����
<br /> Register of Deeds
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<br />
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