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<br /> PHS-798 (VS) Reu. 4-4$. Federal Security Agency, Pu61ic Health Seroice. (Confaining 475 printed words}
<br /> NO. 188-THEFUGUSTINECO.GR�NDISLRND.NEBR. �
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<br /> I �TA?6 Of t�S88A5KB� Filed in the o�ce of t6e Register of Deeds the daU
<br /> CERTIFICATE OF DEATH � �"°i of 19 , and recorded in Misce[laneous
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<br /> Record No. on Page .
<br /> OF � .
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<br /> Reqisler of Deeds-Countg Cferk.
<br /> 1
<br /> I
<br /> � App[ies to R. E. Descripfion By Deputy.
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<br /> - - - - - - - - - - - - - - - - - - - - - -'- -viz:- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
<br /> STATE OF NEBRASKA
<br /> DEPARTMENT OF HEALTH �i
<br /> Birth No. suresu oi v�tal stat�st�cs State File No.
<br /> 1. PL E OF D A H 2. USUAL RESID ere ecease ltve . f mstduLon: resi ence e ore a m�sston).
<br /> a. COUNTY a. ST:1TE b. COUNTY
<br /> [>, CI fpY� (If outside corporate limits,write Ruraq. I a LENGTH OF STAY(in thia place) c. CI�Y� (If outside corporate limita,write RURAL)
<br /> TOWN TOWN
<br /> d. FULL NAME OF (If not in hospital or institution,give street address or location) d. STREET (If rwal,give location)
<br /> HOSPITAL OR ADDRESS
<br /> INSTITUTI ON
<br /> , a. irst) , ( i e) c. ( ast) i 4. ODF Month) ( aY) (Year)
<br /> DECEASEO
<br /> DEATH
<br /> (Typ�o�P�int)
<br /> b. SEX 6. COLOR OR RACE T. MARRIED,NE R MARRIED, 8. DATE O BIRTH 9. Age(In yrs. It Under 1 Year If Under 24 Hra.
<br /> ( ( WIDOWED,DIVORCED (Specify) I I last birthday) Mos. I Days Hours f Min.
<br /> t0a. USUAL OCCUPATION (Give kind of work done during I 106. KINll OF BUSINESS OR 77. BIRTH- (City,town or county)(State or foreign 12. CITI'LEN OF WHATI
<br /> most of working life,ev�n if retired) INDUSTRY I PLACE country) � COUNTRY?
<br /> � 13. FATHER'S NAME � I 14a. MOTHER'S MAIDEN NAME I 14b. NAME OF HUSBAND OR WIFE
<br /> 16. WAS DEC.EASED EVER IN U.S.ARMED FORCES`t 16. SOCIAL SECURIT No. 17. INFORMANT'S NAME or Signature&Address
<br /> (Yes,no,or unknown) I (If yes,give war or dates of service)
<br /> 18. CALTSE OF DEATH MEDICAL CERTtFICATION In!e�val Betwsen Onset
<br /> Entcr only one cause per and Death
<br /> line for (a). (b),and (c) �, DISEASE OR CONDITION
<br /> DIRECTLY LEADING TO DEATH•
<br /> (a) -
<br /> •This doss aot mean th• ANT�CEDENT CAUSES
<br /> mods oT elylnp, such as
<br /> heart failurs, asthenla,
<br /> �tc. It m�ans the dis- DUE TO (b) --
<br /> ease, InJ4ry, o� compll-
<br /> eation whieh causad Mo�bid eondittons, ii any, plviny -
<br /> dsath. �•tae to the above cause (a)atatinp
<br /> � -� � � the unds�lyiny eauas last. DUE TO (c) _-_--
<br /> Ii. OTHER SIGNIFICANT CONDITIONS
<br /> Conditions conl�Ibutiny to the dealh but nct
<br /> relsted to the diseaas o�condt4lon eausiny dsatb.
<br /> 19a. DATE OF OPERA- I 79b. MAJOR FINDINGS OF OYERATION I 20: AUTOPSYI
<br /> TION +;
<br /> Y�9� No ❑
<br /> 21a. ACCIDENT (Specify) 21b. PLACE OF INJURY (e.g.,in or abaut home,farm. 21e. (CITY OR TOWN) (CUUNTY) STA7'E)
<br />, SUICIDE I factory,street,ofI'ice bldg.,etcJ I (If rural area,write RURAL)
<br /> HOMICIDE
<br /> 27d. TIME (Month) (Day) (Year) (liour) I 21s. INJURY OGCURR�D I 27f. HUWDID INJURY OCCUR? ,�......
<br /> OF While at Work �
<br /> INJURY m• Not While at Work ❑ -
<br />� 22. I hs�eby o��tlfy tha! I attend�d ths deceased f�om� , 79 , to _, 19 , tha! 1 las!s:aw th•
<br /> i deeeased alivs on- , 79 , and lhat dealh ooeurrod at _m.,irom 4h�causes and on th�dals statsd abovs.
<br /> 23a. SIGNA7'URh (Degree or title) I 23b. ADDRESS � 23c. llATE SIGNED
<br />� 24a. BURIAL,CREMATION, 24b. DATE 24e. NAME OF CEMET'ERY OR GRBMATORY I 24d. ,.00ATION (City,town,or county) (State)
<br /> REMOVAL (Specify) l I
<br />' DATE RFC'U liY LOCAL REG. ( REGISI'RAR'S SIGNATU'RE 26. FUNERAL DIRECTOR'S SIGNA7'URE ADDRESS
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