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�V� <br /> l�Y� ������l�l �� �J � ��� �1`� JL <br /> 17604—The Augustine Co., County Suppliea, (}rand Island, Nebr. <br /> CER�rIFICATE OF DEATH. � <br /> DEPARTMENT OF HEALTH <br /> N0. 5205 D Division of Vital Statistics 3�042 <br /> STANDARD CERTIFICAIE OF <br /> DEATH <br /> C�'JN1Y-D`�IIGLAS Ci�y of Oma.ha, l�ebra.ska. <br /> l. PLAC� OF DEAT%i: <br /> (a) County Dougla.s <br /> (b) City or tot�n Omaha ( If outsicle city or toslTn limits, write �'JRAL) <br /> ( c) Name of hospital or institution: <br /> 910 so. 3�th s�. <br /> ( If not in nosbital or institution write <br /> number or location) <br /> (d) Length of s�ay: In nospital or instit��ion. <br /> In this eemmunity l� years. peclfy whetiier) <br /> years , months or d�.ys) . <br /> 3(a) FULL NAME Claude A.Beach <br /> 3. (b) If veteran, nume w�,r. <br /> 4. Sex MALE <br /> 5. Color or r�ce WHITE <br /> 6. (a) Sin�le,widowed., married <br /> divorce� MARRIED. <br /> b. (b) Na,nie of hu s'pand or wif e JENi�1IE BEACH <br /> 6. ( c) A;;e of husbana or ti�rife, if ali��e ---yrs. <br /> ' 7. Birtn date of deceased � 23 1��2 <br /> (Mon�h) (Day) (Year) <br /> �. AGE: Years Months Days If less tri<�n one d�y <br /> 5� 9 21 __�_____rlr.-----rnin. <br /> 9.Birthpla.ce Ridgeway Michigan <br /> City, Town or Count,y-�tate or foreign country <br /> 10. Usual occu�ation locomotive en��ineer <br /> 11. Industry or b,asiness R. R. <br /> 12 F�.tner} Name Beach <br /> 1� " ) Birthplace Unknocvn <br /> 1 . M ther) Ma.iden name Unkno-�m <br /> 15. ��• ) Birthplace Unknown <br /> 16. (a) Inf'ormant ' s own signature Jennie Beach <br /> (b) Address 910 So. 3�tn St. <br /> 17. (a) removal <br /> ( �urial, crem��tion, or removal <br /> (b) Date thereof 6-17-�I <br /> Mcnth Day Year <br /> ( c) Place : bUrial or cremation G�^and I51and, Nebr. � <br /> l� (a) 5ionature of funeral dir�ctor Crosby-Meyer <br /> (b) Address Omaha., Nebr. <br /> 19 (a) 6-17-�+1 <br /> Da.te received loc�l re�istrar • <br /> (b) R.A.Harman <br /> , Re�istra.r' s signature <br /> 2. UsUAL RESIDENCE OF DECEASED <br /> (a) State Nebrasi;a (b) �ounty Douglas <br /> ( c) City or town Omaha <br /> ( If outside city or to�,,m limits, write ri'JRAL) <br /> ( d) Street No. 910 So. 3�th <br /> ( If rural give location) <br /> ( e) �f forei�ri b�a�ra, riow long in U. S.A. ----years. <br /> MEDICAL CER`I'�F'ICATTDi� <br /> 20. Date o�' deatn Month 6 day 14 19�1 <br /> � :1�5 P. M. hour minute <br /> 21 I hereby certify that I attended tne dece�sed from <br /> April, 19tk1, to 6-14-�1 <br /> tha.t I last s�w h-- a.live on 19--- <br /> and t:rla.t deatn occt�r�'ed on th� da.te and. hour stated above <br /> Imme�iate cause of death <br /> cardiac dilita.tion Dur. ation -1 min. <br /> Due to-double heart lesion <br /> Due to (mitral stenosis a.r:d aortie insufficiency) <br /> 9��� <br /> Oti�er c�nditions --__________ <br /> ( Include ��regn��ncy within 3 nontns of death) <br /> Ma,jor findin�s: � P�iYSICIAN <br /> Of operations ---------------- Underline the cause <br /> Of autopsy --------------- to which de��th shou�d <br /> bE cnar ged statistically. <br /> 22. If deatn was due to external causes, fill in the followin� <br /> (a) Accident, suicide, or nomicide � specify) <br /> (b) Da,te of occurence <br /> ( e) �^��iere did injury occur -__---_�--------------------------- <br /> City or town County State <br /> (d) Did irijury occur in or about home, on fgr;�l, in industrial place <br />, in ;�ublic place ----------------------- <br /> ( S,�ecify t .�e of pl� ce) <br /> Wnile a.t work ------------� e� Means of in ury -------- <br /> 23. 5ignature R. T�1ornP11 M�uer (M. D. or other � <br /> Address 15�h and Dod,;e D�.te signea 6-16-�-1 <br /> I hereby certify th��.t the a�ove is a true a.7d correct copy of trle certifia��te of death <br /> recorcied in trie City of Omana, County of Dou 1.as, State of Nebrasl�� . <br /> Dated this �th d<y of August, 19�+1. ( SEAL� R.A. H�rmon,Re�istrar. , <br /> Fi1ed for record this 19th day of August, 19�1, at 1: �� o � clock P.i�. � <br /> ! �- �s.�.� i <br /> ' -�-� -�-�-,a���-� <br /> � <br /> � __. � <br />