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<br /> PHS-798 (VS) Reu. 4-48. Federal Securitg Agency, Public Health Seruice. (Containing 475 prinfed words}
<br /> NO. 188-TNE�UGUSTINECO.GR�NDISIAND.NEBR. � .
<br /> 1
<br /> I tA?L OF tJt8RA5ttA Filed in the o�ce of fhe Register of Deeds the 7 day
<br /> CERTIFICATE OF DEATH i �� Hall � of April Is 52 , and recorded in Miscellaneous
<br /> � Record No!�Qn on Page 215.
<br /> OF � �
<br /> � eqt'dste o Deeds-�iremi�Glerk.
<br /> John Martin Duggan �
<br /> , � Applies to R. E. Description By Zkpufy.
<br /> /'+`�'
<br /> I
<br /> - - - - - - - - - - - - - - - - - - - - - -�- _oiz: S�of Las 4-5-6,_Bl._16�Wood River- - - - - - - - - - - - - - -
<br /> STATE OF NEBRASgA
<br /> DEPARTMENT OF HEALTH
<br /> Birth No�26 suresu ot vitat stacistics State File No. SfL-C 7L7 998
<br /> 1. PL OF DEA N 2. USUAL RE ID N E ( ere ecease ltve . f instttuUon: rea� ence e ore a mission).
<br />' a. COUNTY Hall D-25� a• ST.1TE N@bTd3k8. b. COUNTY H811
<br /> b, crrY (If outside corporate limits,write Rurap. c. LENGTH OF STAY(in this place) c. CITY (If outside corporate limits,write RURAL) ,
<br /> OR OR
<br /> TOWN �rand Island 6 davs TOWN Wood River .
<br /> d. FULL NAME OF (If not in hospital or institution,give street addreas or ocation) �d. STREET (If rural,give location)
<br /> HOSPITAL OR ADDRESS
<br /> INSTITUTIONst. Francis� 131� W@St: Charlec
<br /> �. M O a. rtrst) . ( ia e) c. st) I 4. OFT Month) (llay) (YeBr/
<br /> DECEASED I
<br /> cTrp•o�P�+��> I ohn �r�• i DEATH
<br /> 6. SEX 6. COL R OR RACE 7. MARRIED,NEVER MARRIED, 8. ATE OF BIRTH 9. Age(In yrs. Ii Uuder 1 Year If Under 24 Hrs.
<br /> WIDOWED,DIVORCED (Specify) last birthday) Mos. Days Hours I Min.
<br /> Male I White � Married Ai 16_ 1s72 I 7d I
<br /> t0a. USUAL OCCUPATION (Gtve k�nd of work done dunn I 70b. K1Nll OF BUSINESS OR 71. BIR - (Ci y,town or county)(State or forei n 12. CITI'LEN OF WHAT
<br /> most of working life,even if retired) INDUSTRY PLACE country) COUNTRY7
<br /> g I 8
<br /> FarmeT � Wood River� Hall Co. Nebr, llnited States
<br /> 73. FATHER'S NAME t4a. MOTHER'S MAIDEN NAME 14b. NAME OF ltIISS�l7QD'OR WIFE
<br /> Patrick Dtteean I Ellen O�Brien I Marv � Francic
<br /> 15. WAS DECEASED �.'Q�R IN U.S.ARMED FORCES`l 76. SOGIAL SECURITY No. 17. INFORMA T'S NAME or Signature&Addresa
<br /> (Yes,no,or unknown) I (If yes,give war or datea of service)
<br /> 78. CAUSE OF DEATH Intswal Bstw�sn Ons�t
<br /> Enter oniy one cause per MEDlCAL CERTIFICATION and Death
<br /> line for(a), (b),and(c) �, DISEASE OR CONDITION
<br /> DIRECTLY LEADING TO DEATH" ��ardial infaret 6 davs
<br /> ca>
<br /> •This does aot mean!h• ANT�CEDENT CAUSES
<br /> mode ef dyinp, sueh as
<br /> heart tailurs, asthsnla,
<br /> �tc. It m�yns ehs dis- DUE TO (b) Arteriosclero�.ia _yrs.
<br /> i esse, injury, o� compli- - �
<br /> catlon which eaus�d Morbid condltions, it any, ytvinp
<br /> dsath. �•Ise to tha abov�causs (a)stA4iny
<br /> the unde�lyiny causw last. DUE TO (c) - --
<br /> 11. OTHER SIGNIFICANT CONDITIONS
<br /> Conditions contributinp to the dsath but net
<br /> rslated!o ths diseaae o�conditlon causlnp d�ath.
<br /> 19s. DATE OF OPERA- I 19b. MAJOR FINDINGS OF OPERATION 20. AUTOPSY`l
<br /> TION y¢s 0 No ❑
<br /> 21a. ACC.IDENT (Specify) I 21b. PLACE QF INJURY (e.g.,in or about home,farm. 21a (CITY OR TOWN) (COUNTY) (STA1'E)
<br /> SUICIDE factory,street,ofi"ice bldg.,etc.) (If rural area,write RURAL)
<br /> HOMICIDE
<br /> 21d. TIME (Month) (Day) (Year) (I-four) I 27e. INJURY OCCURR�ED I 27f. HOW DID INJURY OCCUR?
<br /> OF While at Work �
<br /> ilaIJ1TRY m• Not While at Work ❑
<br /> 22. 1 hsreby e��tify that I a t�nd�d !he dsesased from 9,/13 C^ , 79�,.,�_C,^to,� 12�2-; _, 19�Q, that 1 last saw th•
<br /> dseeased alive on 12�23 19�L]L� and that dsalh occwr�ed aiil�f�am. irom th�eauses and on ti��dat�stat�d above.
<br /> 23a. SIGNAI'URh (Degree or title) 23b. ADDRESS 230. DATE SIGNED
<br /> T. Ervin King M. D. I Wood River Nebr. 12�27,(50
<br /> 24a. BURIAL,GREMATION, 24b. DATE 24e. NAME OF CEMETERY OH GRE.MATOHY 24d. ..00ATION (City,town,or county) (State)
<br /> REMOVAL (Specify)
<br /> Burial I Dec 21, 50 I St. Marys Wood River� Nebr.
<br /> DATE RF'G'L f3Y LOCAL REG. R�(iIS1'RAR'S SIGNATURE 2b. FUNERAL DIRECTOR'S SIGNA7'URE ADDRr:SS
<br /> _DEC 29 195(1 F. S. White R. E. Apfel Wood River. Neb.
<br /> 25. I hereby certifq I personally embalmed the body of the deceased named hereon.
<br /> Raymond E. Apfel
<br /> License No. 1589
<br /> THIS CERTIFIES THE ABOVE TO BE A TRUE COPY OF AN�'ORIGINAL CERTIFICATE ON FILE WITH THE STATE DEPARTMENT OF HEALTH
<br /> BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br /> I
<br /> (SEAL) C. L. Chism
<br /> DIRECTOR OF VTTAL STATISTICS AND ASSISTANT
<br /> STATE REGISTRAR
<br /> LINCOLN, NEBRASKA Issued April 4, 1952.
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