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<br /> _ PHS-798 (VS) Rev. 4-48. Federal Security Aqency, Public Health Service. (Containireg 475 printed tvords}
<br /> NO. T68-TME�UGUSTINE`0.6R�NDISLIIND.NEBR. ' . �
<br /> I ?A?6 OF rtE8RA5KA Filed in the o,(jice of ihe Register of Deeds the �j day
<br /> CERTIFICATE OF DEATH i ./�'a Ha11' � oj Ju 1y��� 195]. , and recorded iR Misceflaneavs
<br /> � Record No. ��'v'� on Page Z 11.
<br /> OF
<br /> � ����
<br /> �*, � � eqR ister of Deeds-E'.esu�t�-Glerk.
<br /> Mary SA,hoenheiter i
<br /> � Applics to R, E. Description By Dcputy.
<br /> � Lo�� �+, Blk.�,Hann�s 3rd.
<br /> - - - - - - - - - - - - - - - - - - - - - -'- -oiz:- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
<br /> 3TATE OF NEBRASHA
<br /> DEPARTMENT OF HEALTH
<br /> Birth No. i26 su�u ot vitgr stat�ci� State File No.
<br /> 1. P OF D 2. USUA E ID N ( ere ecease ive . f inst�tuUon: resi ence ore a isa�on).
<br /> a. COUNTY Hall a. sT.�TE Nebraska b. COUNTY Ha.l.�-
<br /> .CI'PY (If outside corporate limits,write Ru�al). a LENGTH OF STAY(in thia place) a CITY (If outaide corporate limita,write RURAL)
<br /> To°wN arand I s land I 3 we eks TOWN Grand I sland
<br /> d. FULL NAME O� (If not in hospital or inatitution,give street address or Iceation) d. STREET If ,�ve location)
<br /> HOSPITAL OR ADDRESS 315 South' Kim1�a�`
<br /> INSTITUTION Lut�eran Hospital
<br /> ME O . a. ►rst) . ( i e) c. ast) 4. Month) llay) ear�
<br /> � DECEASED �ar� Schoenheiter I DEATH �ay 3� 19�1
<br /> (TYP�K Pr(nt) �
<br /> 8. SEX 6. COLOR OR RACE 7. MARRIED,NEVER MARRIEV, B. DATE OF B1RTH 9. Age(In yrs. If U�der 1 Year If Under 24 Hra.
<br /> Femal� W�lj.t+� WIDOWED,DI ORCED (Specify) last b' day) Mos. Days Hours Min.
<br /> I I m�.rr�ed I �-23-1£�79 I �� � �
<br /> t0a. USUAL OCGUPATION (Give kind of work dane durin 10b. KINll OF BUSINESS OR 11. BIRTH- (City,town or county)(State or forei n 12. CITI'LEN OF WHAT
<br /> most of working liPe,even if retired) INI?USTRY PLAC country) COU R
<br /> House�rif� g I Hom� I �vansville, Ind�ana �.�.
<br /> 13. FATHER'S NAME 14a. MOTHER'S MAIDEN NAME 14b. NAME OF HUSBAND OR WIFE
<br /> August EickhaPf I Louis� Libbing ( Erhar�dt Schoenheiter
<br /> 16. WAS DECEASED EVER I1V U.S.ARMED FORCES2 16. SOGIAL SECURITY No. 17. INFOi2MANT'S NAME or Signature&,Address
<br /> (YeOs,no,or unknown) I (If yes,give war or datea of service) n� E• ►gCih.��enhei t er,Grand I sland
<br /> n ,,
<br /> 78. CAUSE OF DEATH In!erral B�twt�n Ons�t
<br /> Enter only one cause per MEDICAL CERTIFICATION and DsaLh
<br /> line for(a), (b),and (c) �, DISEASE OR CONDITION
<br /> DIRECTLY LEADING TO DEATH• �a� 1 1 crmm�n r � 1ri ��v 2_�r'g,
<br /> •This do�s not m�an tA� ANT�CEDENT CAUSES
<br /> mods of dyinp, sueh ss
<br /> hssrt fallurs, astbenia,
<br /> �to. It m�ant tMs dIs- DUE TO (b) -
<br /> esse, injury, or eompli-
<br /> eatlon wl�ich eaus�d Mo�bid eonditlons, If any, piviny
<br /> d�ath. riss to the abovs cause(a) stwtlnp
<br /> the und��lylny eauas last. DUE TO (c) ----
<br /> 11. OTHER SIGNIFICANT CONDITIONS
<br /> Conditlons cont�ibutfny to!he d�atb but nct
<br /> rslated to the diaease o�condition causi�y d�atl�.
<br /> 19s. DATE OF OPERA- I 19b. MAJOR FINDINGS OF OYF.RATION 20. AUTOPSY?
<br /> TION
<br /> Yes ❑ No �}
<br /> 21s. ACCIDENT (Specify) I 21b. PLACE QF INJURY (e.g.,in or about home,farm. 21c. (CITY OR TOWN) (COUNTY) (STA7'E)
<br /> SIJICIDE factory,street,office bldg.,etc.) (It rural area,write RURAL)
<br /> HOMICIDE
<br /> 21d. TIME (Month) (Day) (Year) (ffour) 21s. INJURY OCCURR�D 27f. HOW DID INJURY OCCUR?
<br /> OF I While at Work � I
<br /> INJURY m. Not While at Work ❑
<br /> 22. I F�s�eby csrlity lhat 1 att�ndsd ths dac:ased f�om- ��"� , 19 �, to r�t�T� -, 19�.�-. lF�a! 1 last s:aw th•
<br /> deceased alivs on MS-� �1� 19�_ and tAa!dealh oecur�ed a � �m.,i�om th�eauses and on ths date statod abore.
<br /> 23a. SIGNAI'URh (Degree or tiUe) 23b. ADDRESS 23e. ATE SIGNED
<br /> C. H« Maggoire M. �. I Grand Island, N�br. � ���! ��
<br /> 24a. BURIAL,I:REMATION, 24b. DATE 24e. NAME OF CEMETERY OR Gki�MATORY 24d. a.00ATIOI�I (City,town,or county) (State)
<br /> REMOVAL (Specify) Z
<br /> Burial I '�-2_-_51 I Grand Island Grand Island, Nebr.
<br /> DATE RNC'll HY LUCAL REG. REUIS AR'S �IGNATURE 26. FUNEHAL DIRECTOR'S SIGNA7'URE ADLlR�SS
<br /> Jun 7 1951 F. S. White I Livingston-Sondermann, Grand Island, Nebr.
<br /> 25. I hereby certify I personally embalmed the body of tne d�ceased named herein.
<br /> Ja.mea D. Livingston Licenae No. 1�35
<br /> THIS CERTIFIES THE ABOVE TO BE A TRUE COPY OF AN ORIaZNAL CERTIFICATE ON FILE t�+IITH THE STATE
<br /> DE�'ARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY FOR V�TAL REC�RDB.
<br /> (g�,) �; C. L. Chiam
<br /> D E OR 0 S A S CS AND ASS ANT
<br /> RF�I S TRAR.
<br /> LINCOLN, NEBRASKA JCJN 16 1951.
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