|
• o o � l�
<br /> -� << � �� ��. �� � �. � � � � � � �. ��. �
<br /> PHS-798 (VS) Rev. 4-48. Federal Security Agency, Public Health Seruice. (Containing 475 printed mords}
<br /> NO: 188-TNEAUGUSTINECO.GR�NDISLAND.NEBR. ' �
<br /> I TR?S Of' tJ£88A5KA
<br /> _�rr Filed in the o�ce of fhe Regisier of Deeds the 11-� day
<br /> CERT�FICATE OF DEATH i ��'0° HALL � of June 19,5� , and recorded in Miscellaneous
<br /> " Record No. Q on Page 21'7
<br /> �F , ��� C���
<br /> HENRY BADY � Register oj Deeds--�('se�C,lerlF
<br /> i �
<br /> � Applies to R. E. Description By Depufy.
<br /> �� � Lots 10-I1-12-13-I� B1k. 1�, Meths Add.
<br /> -' - - - - - '- - - - - - - - _ _ _ _ - _ _ -i_ _DZ._ - - - - - - - - - - _ _. _ - _ _ � - - - - - - - - - - - - - - -
<br /> STATE OF NEBRASKA
<br /> DEPARTMENT OF HEALTH
<br /> Birth No. 12 6 Bureau ot vital stat�sttca Siate File No.
<br /> 1, P OF DEA N 2. USUA ID CE ( ere ecease l�v , insUtution: resi ence e ore a mtssion).
<br /> a. COUNTY H�� a. ST.1TE Nebrask�. b. COUNTY Ha,ll
<br /> . CI'fY (If outaide corporate limits,write Rural). c. LENGTH OF STAY(in thia place) c. CITY (If outaide corporate limita,write RURAL)
<br /> TOWN Grand Island I TOWN Grand Island
<br /> d. FULL NAME OF (If not in hospital or institution,give atreet address or location) d. STREET (If rural,give location)
<br /> HOSPITAL OR ADDRESS
<br /> INSTITUTION St. Francis Hospital 904� Eas� 15th Street
<br /> �. N M O a. ust) . (�e) c. st) 4. DO�T Month) (llay) ( ear�
<br /> DECEASED Henr B�`�.,d I DEATN `L 1 195'�'
<br /> (Type or Print) Y Y
<br /> 6. SEX 6. COLOR OR RACE 7. MARRIED,NEVER MARRIED, S. DATE OF BIRTH 8. Age(In yrs. If Under 1 Year If Under 24 Hrs.
<br /> OWED,DIVORCED (Specify) las rthday) Mos. D ys Hours Min.
<br /> Ma1e I Whit� I �arried 12-25-1877 I �j� 1 � �i ( �
<br /> 10a. USUAL OCCUPATION (Give kind of work done during 10b. KINll OF BUSINESS OR 71. BIRTH- (City,town or county)(State or foreign 72. CITI'LEN OF WHAT
<br /> most working life,even if retired) DUS RY PLACE c try) C N RY7
<br /> �armer I �arm�ng I Duncanvi��e , Ohio U.�'.A.
<br /> 73. FATHER'S NAME 14a. MOTHER'S MAIDEN NAME 14b. NAME OF HUSBAND OR WIFE
<br /> - - - - Bady I I Leana Baumann Bady
<br /> 16. WAS DECEASED EVER IN U.S.ARMED FORCES4 16. SOCIAL SECURITY No. 17. INFORMANT'S NAME or Signature&Address
<br /> (Yes, or unknown) I (If yes, ve war or dates of service)
<br /> �l'o l�o N� --- Mrs. Henr Bad Grand Isl.and, Nebr.
<br /> 18. CAUSE OF DEATH Ir.!��val B�twNn Ons�t
<br /> Enter only one cause per MEDICAL CERTIFICATION and Death
<br /> iine tor(a), (b),and(c) �, DISEASE OR CONDITION
<br /> DIRECTLY LEADING TO DEATH• Cancer O� stomach
<br /> ca� -
<br /> •This does eot msan th� ANT�CEDENT CAUSES
<br /> mods of dyfny, such as
<br /> beart faiturs, astbenla,
<br /> �tc. it m�gns !he dis- DUE TO (b) ---
<br /> saae, Inju�y, or compll-
<br /> cation whioh caussd Mo�bid eondilions, if any, ylvinp
<br /> d�ath. rlse to the abovs esuae (a)alatiny
<br /> the unds�lyiny esuss Iaat. DUE TO (c) ----
<br /> 11. OTHER SIGNIFICANT CONDITIONS
<br /> Conditions eont�ibutiny to the dssth but nct
<br /> �elated to ths dissase o�conditlon eausinp d�ath.
<br /> 79a. DATE OF OPERA- I 196. MAJOR FINDINGS OF OYERATION j 20. AUTOPSY't
<br /> TION I y� � No ❑
<br /> 21a. ACCIDENT (Specify) I 21b. PLACE QI�' INJURY (e.g.,in or about i�otne,farm. 21e. (CITY OR TOWN) (COUNTY) (STA1'E)
<br /> SCIICIDE factory,street,oQ'ice bldg.,etc.) (If rural area,write RURAL)
<br /> HOMICIDE
<br /> 21d. TIME (Mont6) (Day) (Year) (I-four) I 21s. INJURY OCCURR�D 27f. HOW DID INJURY OCCUR7
<br /> OF While at Work ❑
<br /> INJURY m• Not While at Work ❑
<br /> 22. I hersby es�tlfy that 1 a n d th• deesased from 1-Q°1- , 19 � to 2-1 -, 19.�1�, lhat 1 last saw !h�
<br /> deeeased alivs on- �� ,19 ,and tha!death ooeurr�d a�!m.,trom tl�s eauses a�d on th�dat�statsd above.
<br /> 23a. SIGNATURh (Degree or title) 23b. ADDAESS I 23c. DATE SIGNED
<br /> K. F, McDermott, M.D. Grand Zsland, Nebr. 2-7-52
<br /> 24a. BURIAL,I:REMATION, 24b. DATE 24e. NAME OF CEMET'ERY OR CHF.MA7'ORY 24d. ,.00ATION (City,town,or county) (State)
<br /> RE VAL (Sp cify)
<br /> �uria.� I 2-�-19.�2 I Westla.wn Memorial Park Grand Island, Nebraska
<br /> DATE REC'L liY LOGAL REG. REUISTRAR'S SIGNATURE 25. FUNERAL DIRECTOR'S SIGNA7'URE ADDRESS
<br /> Feb 11 1952 F . S. White I L3vingston-Sondermann Grand Island, Nebraska
<br /> 25. I hereby ce.r�ify I personall.y emba�.med the body of the deceased named hereon.
<br /> James D. Livingston License No. 183�
<br /> THZS CERTIFIES THE ABOVE TO BE A TRUE COPY OF AN ORIGINAL CERTIF2CATE ON FILE WITH THE STATE
<br /> DEPARTP�IENT OF HEALTH, BUREAU OF VITAL S�ATISTTCS, WHTCH IS THE LEGAL DE�'OSITORY FOR VI�AL RECORDS.
<br /> (SEAL) C . L. Chism
<br /> DIRECTOR OF VT�'AL STATISTICS
<br /> AND ASSISTANT STATE REGZSTRAR.
<br /> � LINCOLN, NEBRASKA
<br /> Issu�d June l2, 1952
<br />
|