|
0 0 �l � �
<br /> � � � � � ��. � �. � � � � � � �. ��.
<br /> �HS-798 (VS) Rev. 4-48. Federal Securit�Agencg, Public Health Seroice. (Containinq 475 printed uwrds}
<br /> NO. 18B-TXEAUGUSTINECO.GR�NDISLIIND.NEB11. ` � � -
<br /> 1 ?BT6 Of NS88A5KR
<br /> Filed in the o„(j'ice of[he Register of Deeds the 25 day
<br /> CERTIFICATE OF DEATH � � Hall � of January Is 52 , ared recorded in Miscellaneous
<br /> Record No. rtett on Page 213.
<br /> OF � �� ��
<br /> ^ � � �egister oj Dteds-Countg C[erk.
<br /> Em�na Edith Holder. ` �
<br /> � Applies ta R. E. Deseription Bg Deptriy.
<br /> i
<br /> Lot 6, Blk. 2, Boggs and Hills Addition
<br /> - - - - - - - - - - - - - - - - - - - - - -'- -oiz:- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
<br /> STATE OF NEBRASgA True copy of original death Certificate.
<br /> DEPARTMENT OF HEALTH Glenn H..Geddes
<br /> Birih No. 126 suresu ot vitat statistics State File No.
<br /> 7. P OF DEA H . USUA E ID NCE (W ere ecease l�ve . inst�tution: res► ence e ore misston).
<br /> a. COUNTY Hall a. ST.1TE Nebr b. COUNTY Hall
<br /> .CI'OY� (If outside corporate limits,write Rural). c. LENGTH OF STAY(in this place) c. CI�Y� (If outside corporate limita,write RURAL)
<br /> TOWN Grand Island I ___ TOWN Grand Island
<br /> d. FULL NAME OF (If not in hoapital or inatitution,give street address or Iceation) d. STREET (If rural,�ve lceation)
<br /> NSTITUTION 2��'rJ W. 13th St. ADDRESS 20�5 W. 13th St.
<br /> . M O a. ►rst) . ( i e) c. ast) 4. ODF Month) WaY) ( ear)
<br /> DECEASED E�a Edith Holder � NOV•
<br /> (Typ�o�Prin4) DEATH g 1945
<br /> 6. SEX 6. COLOR OR RACE 7. MARRIED,NEVER MARRIED, 8. DATE OF BIRTH 9. Age(In yrs. If Under 1 Year If Under 24 Hrs.
<br /> Fema.le I white I wI'�iarrie�VORCED (Specify) TUly 26�e88 I lasr,t�irthday) I Mo3s. I D13 I Hours I Min.
<br /> � 1
<br /> 10a. USUAL OCCUPATION (Give kind o4 work done during 10b. KINll OF BUSINESS OR 71. BIRTH- (City,town or county) (State or foreign 12. CITI'LEN OF WHAT
<br /> most o w rking life,even if retired) INDUST PLACE c try) COUNTRY?
<br /> A� �ome I Housewi�e I Shic�C�ep, Nebr. US.
<br /> 13. FATHER'S NAME 14a. MOTHER'S MAIDEN NAME 14b. NAME OF HUSBAND OR WIFE
<br /> Ham Burch I Eldora Ward I James A. Holder
<br /> 16. WAS DECEASED EVER IN U.S.ARMED FORCES`I 16. SOCIAL SECURITY No. 1T. INFORMANT'S NAME or Signature&Addresa
<br /> (Yes,no,or unknown) (If yes,give war or datea of service)
<br /> no I James A. Holder Grand Island Nebr.
<br /> 78. CAUSE OF DEATH Inle�val B�twe�n Ona�!
<br /> Enter only one cause per MEDICAL CERTIFICATION and Dealh
<br /> line for(a), (b),and(c) �, DISEASE OR CONDITION
<br /> DIRECTLY LEADING TO DEATH• Angina pectoris
<br /> (a) -
<br /> •This doss oot mean th• ANT�CEDENT CAUSES
<br /> mods ot alyinp, such as
<br /> heart Tailurs, asthania, �
<br /> �tc. It msans th• dis- DUE TO (b) -
<br /> sase, inju�y, o� compii-
<br /> catlon whieh caussd Mo�bid eonditions, if any, pivinp
<br /> d�atM. rise!o!he abovs eauae(a) statlnp
<br /> � ths unda��yfny eaus�lasl. DUE TO (c) -- -
<br /> 11. OTHER SIGNIFICANT CONDITIONS
<br /> Condttlons cont�Ibutiny to 4he dealb but net
<br /> �sla4ed to 4hs dissase o�condltion eausiny d�a!!�.
<br /> 79a. DATE OF OPF,RA- � 79b. MAJOR FINDINGS OF OPERATLON I 20. AUTOPSYI
<br /> TIOI�I
<br /> Yes ❑ No RJ
<br /> 21a. ACC.IDENT (Specify) 27b. PLACE QF INJURY (e.g.,in or about homc+,farm. I 21a (CITY OR TOWN) (CUUN1'Y) (STA7'E)
<br /> SITICIDE I factory,street,otl'ice bldg.,etc.) (If rural atea>write RURAL)
<br /> HOMICIDE
<br /> 21d. TiME (Month) (Day) (Year) (Ifour) 21s. INJURY OCCURR�D I 27i. HUW DID INJURY OCCUR?
<br /> OF While at Work ❑
<br /> INJURY m- Not While at Work ❑
<br /> 22. 1 he�eby csMify that 1 att�nd�d th� dscsnsed i�om , 19 , to -, 19 , tha! 1 last s:�w th•
<br /> daceased ativs on� , 19 , and lhat dealh ooeu��sd st -m.,1�om the oaussa and on th�dat�statad abova.
<br /> 23a. SIGNATURh (Degree or title) 23b. ADDRESS 23c. DATE SIGNED
<br /> N. A. Zuspan 0. D, I Grand Island, Nebr I Nov. 10;45
<br /> 24a. BURIAL,CREMATION, 24b. DATE 24e. NAME OF CEME'TERY OH CHF.MATORY 24d. ,.00ATION (City,town,or county) (State)
<br /> REMOlTr�L (S ecify)
<br /> Burial I Nov. 13/45 I Grand Island Crand Island. Nebr.
<br /> DATE REC'll l3Y LOCAL REG. I RE(iISTRAR'S SIGNATU'RE 26. FUNERAL DIREGTOR'S SIGNAI'URE ADDRESS
<br /> Geddes Funeral Home, Grand Island. Nebr.
<br /> 25. I hereby certify I personally embalmed the body of the deceased named hereon.
<br /> J. Walter Geddes.
<br /> S'��'E OF Nebraska ) License No. 1738.
<br /> ) ss: Personally appeared before me this 22nd dap of October, 1951, Glenn H. Geddes, to me knowm
<br /> County of Hall ) to be the identical person who signed the within copy of the death certificate of Emma Edith
<br /> Holder, deceased, and being duly sworn, deposes and says that the within certificate is true,
<br /> correct and complete copq of death certificate now on file in the Geddes Funeral Home in Grand Island, Nebraska; that
<br /> he personally attended the funeral of the said F.m�na Edith Holder and that she was buried in the Crand Island, Cemeterp.
<br /> • IN WITNF,SS WHERIDF, I have hereunto fixed my hand and seal this 22nd day of October, 1951.
<br /> (SEAL) B. .T. Cunningham
<br /> My connnission expires August 5, 1953 . NOTARY PUBLIC
<br />
|