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<br /> PHS-798 (VS) Reu. 4-48. Federal Security Aqency, Public Health Service. (Confaining 4?5 printed words}
<br /> � NO. IBB-THEIIUGUSTINECO.GRAI:DISL�ND.NFB11. �
<br /> I TA?S Of tJ£8RA5ttA Fi[ed in ihe o�ce of ihe Register of Deeds the 9 day
<br /> CERTIFICATE OF DEATH � ,��°"� Hall � of M,µy� 19 52 , and recorded in Miscellaneous
<br /> i
<br /> � Record No. Qtt on Page 216,
<br /> �F • �d�,,,.�.��✓
<br /> Gustave N. Cornelius � Regtster of Deeds-�1e1d0[
<br /> I
<br /> � � Applies to R. E. Description �� Dept�ty.
<br /> � uiz: Lot 5 Block 5 Windol h�s Add.
<br /> - - - - - - - - - - - - - - - - - - - - - -'- - - - - - � - - - -�- - - -P - - - - - - - - - - - - - - - - - - - -
<br /> Dr J� � Wnnc�i n
<br /> STATE OF NEBRASKA
<br /> DEPARTMENT OF HEALTH
<br /> Birth No. 126 suresu of vitat stat�atics State File No.
<br /> 1. PLACE OF EATN 2. SUAL RE51 NCE ( ere decease rve . f mst►tution: res� ence e ore a m�ssion).
<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 outaide corporate limits,write RURAL)
<br /> TOWN Grand Island i 85 TOWN Grand Isl�,nd
<br /> d. FULL NAME OF (If not in hospital or institution,give atreet address or location) d. STREET (If rural,give lceation)
<br /> I;NS'TI UTION st. Francis HOSp. ADDRESS 1122 W. John St.
<br /> . NAM OF a. Nirst) . (Mi e) c. ( st) 4. OF Month) (llay) ( ear�
<br /> DECEASED
<br /> (TYP�o�P�in!)
<br /> Gustave N. Cornelius � DEATH March 27 1952
<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 /> WIDOWED,DIVORCED (Specify) last birthday) Mos. Days Hour= I Min.
<br />� Male I White ( Widawed Nov. 9. 1862 89 4 I 18 - -
<br /> 10a. USUAL OCCUPATION (Grve lund of work done dunng ( tOb. KIND OF BUSINESS OR 11. BIRTH- (City,town or county){State or foreign 12. CITILEN Ob WIIAT
<br /> most of working life,even it retired) INDUSTRY I PLACE coantry) COUNTRYY
<br /> Retired Machinist �Americal Crvstal SuFar Cd D�vetiport, Iawa U.S
<br /> 13. FATHER'S NAME I 14a. MOTHE 'S MAIDEI�NAME I 14b. NAME OF HUSBAND OR WIFE
<br /> T Chris Cornelius Doris Rauert Marie Cnrnelius
<br /> 16. R'AS DEC ASED EVER IN U.S.ARMED FORCES? 16, SOCIAL SECURITY No. 1T. INFORMANT'S NAME or Signature&Address
<br /> (Ycs,no,or unknown) (If yes,give war or dates of service)
<br /> I Mr. Walter Cornelius Grand Island
<br /> 16. CAUSE OF DEATH MEDICAL CERTIFICATION �n!srval Between Onset
<br /> Enter only one.cause per snd Dsath
<br />' linefoc(a), (b),and(c) �, DISEASE OR'CONDITION
<br /> DIRECTLY LEADING TO DEATH• �a� S�ock,Lhip fracture 7 d•
<br /> •Tbis does not msan tbs ANT�CEDENT CAUSES
<br /> mods oT alyiny, such as
<br /> hea�t fallurs, asthenia,
<br /> �te. I! msan! !he dis- , DUE TO (b) -
<br /> ease, injury, o� compll-
<br /> eation whiah caused Mo�bid eonditiona, if any, piviny
<br /> d�ath. rlse to the above cauae (a) siatiny
<br /> � � � � the unda�lyln9 cauas Iast. DUE TO (c) _-- _
<br /> 9�4� 11. OTFiER SIGNIFICANT CONDITIONS
<br /> Conditions contrlbutiny to tMe dsalh bu4 net
<br /> I rslated to 4he diseaas o�condition eausiny dsalb.
<br /> 79a. DATE OF OPERA- I 19b. MAJOR FINDINGS OF OYERATION I 20. AUTOPSY4
<br /> TION
<br /> Yes � No ❑
<br /> 27a. ACCIDENT (Specify) 21b. PLACE Ob' INJURY (e.g.,in or abaut homcy farm. 21c. (CITY OR TOWN) (CUUNTY) (STA1'E)
<br /> �{.y���y.. I factory,street,office btdg.,etc.) (If rura!area,write RURAL)
<br /> �°"""�'�'F Accident H Home, Grand Island, Hall Neb
<br /> 21d. TIME (Month) (Day) (Year) (Ho�u� 21s. INJURY OCCUHR�D 21t. HOW DID INJURY OCCUR7
<br /> OF While at Work �
<br /> INJURY p�r 20 t52 6 p• m" Not While at Work �] I Fell in room
<br /> 22. I heroby csrlity 4hat I at4�nd• ths dsc:ased irom_ ,�.�20 , 19��, to 3�27 �_, 19..ab-, lhat I,last s:aw th•
<br />' doesased alivs on_- 3 2? , 79 5� , and that deatM ooeu��ed at � _�.m.,trom ths eauses and on ths dal�atatsd above.
<br /> 23a. SIGNATURh (Degree or title) 23b. ADDRESS 23c. DATE SIC,NED
<br /> J. G. Woodin M. D. I Grand Island f 3-28-52
<br /> 24a. BURIAL,(:REMATION, I 24b. DATE I 24e. NAME OF CEMET'ERY OFt CHB.MATOFtY I 24d. ..00ATION (City,town,or county) (State)
<br /> REMOVAL (Specify)
<br /> Bvri 1 Mar 31 /52 Grand Tcl anc� Grand Island, Neb
<br /> DATE REC'll liY LOCAL REG. RBGiSTRA 'S SI NATURE 25. FUNEHAL llIRECTOR'S SIGNA7'URE ADDRESS
<br /> Apr 4, 1952 I F. S. White Geddes Funeral Home Grand Island, Neb.
<br /> 25.I hereby certify i personally embalmed the body of the deceased named hereon.
<br /> Irwin B. Peterson License No. 1826
<br /> THIS CERTIFIES THE 9BOVE TO BE A TRUE COPY OF AN ORIGINAL CERTIFICATE ON FILE WITH T� STATE DEPARTMENT OF HEAT.TH�
<br /> BUREAU OF VTTAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br /> (SEAL) C. L. Chism
<br /> DIRECTOR OF VTTAL STATISTICS AND
<br /> ASSISTANT STATE REGISTRAR
<br />� LINCOLN, NEBRASKA Issued May 3, 1952.
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