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<br /> PHS-798 (VS) Reu. 4-48. Federal Security Aqency, Public Health Service. (Confaining 475 printed words)
<br /> NO. 188-TNE�UGUSTINE[O.GRAfiDISLANO.NEBR. � � �
<br /> 1
<br /> I ?A?E Of I1S8RA5KB Filed in ihe o�ce of ihe Register of Deeds the 29 dag
<br /> CERTIFICATE OF DEATH � �°"o� Nebraska of October 1'9 51 , and recorded in Miscellaneous
<br /> � Record No. Q on Page 212
<br /> oF � ��..�, ���
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<br /> � � Regisler of Deeds--Eett�t��k.-
<br /> Fred Montague Adams � Applies to R. E. Description By Depaty.
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<br /> Pt. Lot ?, B1. 6, Orig. Town of Doniphan STATE OF NEBRASKA This is to certify this is a true copy.
<br /> DEPARTMENT OF HEALTH Glerirl H: �Gedde3.
<br /> Birth No. 126 Bureau of Vital Statistics Stafe File No.
<br /> 1. P ACE OF EA H 2. USUA R ID N E (W ere ecease �ve . f mst�tution: resi ence e ore a m�sston).
<br /> a. COUNTY Hall a. ST.1TE Nehr b. COUNTY H���
<br /> , CI fOY� (If outside corporate limits,write Rural). I c. LENGTH OF STAY(in thia place) a CI�Y� (If outaide corporate limits,write RURAL)
<br /> TOWN DOt11D�1r�1'► TOWN
<br /> ll�ni rhan
<br /> d. FULL NAME OF (If not in hospital or institution,give street address or location) d. STREET (If rural,�ve location)
<br /> HOSPITAL OR ADDRESS
<br /> INSTITUTION HO�tle
<br /> ME O a. N'irst) . ( i e) c. ( ast) 4. OF Month) Way) (Year)
<br /> � DECEASED I DEATH 11 1951
<br /> cTVp.,�P�,,,t� Fred Monta�ue Adams ! Au�.
<br /> 6. SEX 6. COLOR OR RACE T. MARRIhD,NEVER MARRIED, 8. DATE OF B1RTH 9. Age(In yrs. If Under 1 Year If Under 24 Hrs.
<br /> WIDOWED,DIVORCED (Specify) last birthday) Mos. Days Hours I Min.
<br /> Male I White I Married Feb. 4, 1880 ?1 6 � 7
<br /> 70a. USUAL OCCUPATION (Give kind of work done during I 70b. KINll OF B[JSINESS OR 11. BIRTH- (City,town or county)(State or foreign 12. CITI'LEN OF WHAT
<br /> most of working life,even if retired) INDUSTRY PLACE country) COUNTRY?
<br /> Retired Farmer , Farming I Fontanelle. Iowa USA.
<br /> t3..FATHER'S NAME 14a. MOTHER'S MAIDEN NAME 14b. NAME OF HUSBAND OR WIFE
<br /> Johathan Adams I Mar�aret Thomas I Charolette Adam�
<br /> 75. WAS DECEASED EVER IN U.S.ARMED FORCES`I 16. SOCIAL SECURITY No. 17. INFORMANT'S NAME or Signature&Address
<br /> (Ycs,no,or unknown) (If yes,give war or datea of service)
<br /> no I Mrs h
<br /> 18. CAUSE OF DEATH MEDICAL CERTIFICATION �n`�����Betwe�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• Carcinoma O� stomach
<br /> ca� -
<br /> •This doss no4 ms�n th• ANT�CEDENT CAUSES
<br /> mods oi dyinp, such as
<br /> hsart failure, aa4b�nia,
<br /> �tc. It means tl�• dis- DUE TO (b) -_
<br /> ease, inju�y, o�compli-
<br /> ealion wbioh csused Mo�bid eonditions, It any, plvinp
<br /> dsath. rise to the abovs esuse (a)statiny
<br /> . . . the unde�lyiny eauas lasl. DUE TO (c) -----
<br /> Ii. OTHER SIGNIFICANT CONDITIONS
<br /> Conditions eont�ibutiny to ths dsalh bu!nct
<br /> �elated to tha diaease o�condition causiny dsath.
<br /> 19a. DATE OF OPF,RA- I 79b. MAJOR FINDINGS OF OYERATION 20. AUTOPSYY
<br /> TION
<br /> Yes ❑ No �
<br /> 21a. ACCIDENT (Specify) 27b. PLACE QF INJURY (e.g.,in or about home,farm. 21c. (CITY OR TOWN) (COUNTY) (STATE)
<br /> SUICIDE I tactory,street,olTice bldg.,etc.) (It rural area,write RURAL)
<br /> HOMICIDE
<br /> 21d. OF E (Month) (Day) (Year) (Hour) I 21e. INJURY OCCURR�D I 21�. HOW DID INJURY OCCUR?
<br /> While at Work ❑
<br /> INJURY Tn• Not While at Work ❑
<br /> 22. 1 hs�eby c��tlfy that 1 att�nd�d the decaased f�om_ , 19 to -, 19 , that 1 .last s:�w th•
<br /> deceased alivs on ,19 ,and that doa4h oeeu��sd at��'4Sp- m.,f�om lF�s causes and on lF�s dat�stated abovs.
<br /> 23a. SIGNAI'URh (Degree or title) 23b. ADDRESS 23e. DATE SIGNED
<br /> P� 0 MarvPl M� i �=��tn ��Nebr Aug,� 12J51
<br /> 24a. BURIAL,CREMAT ON, 24b. DATE 24c. NAME OF CEME'TERY OR�MQ�OP[Y 24d. ..00ATION (City,town,or county) (State)
<br /> REMOVAL (Specify)
<br /> BUT181 I Ai��*- 14 1A51 I ('edar View ilnninh�n_�r��j,�
<br /> DATE REC'll liY LOCAL REG. REUISI'RA 'S SIG ATURE I 25. FUNEItAL DIRE(:TOR'S SIGNATURE D �hSS�
<br /> Aue: 15f51 F_ s_ WhitP Geddes Funeral Home Grand Island. Nebr.
<br /> 25. I hereby certify I personally embalmed the body of the deceased named he.reon.
<br /> Irwin B. Peterson Licen�e No. 1826
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