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<br /> 21917—The Augustine Co., County Supplies, Grand Island, Nebr.
<br /> ( d) Str�et No. - --------------------
<br /> �If rural ive lo ati n)
<br /> 3. � e I�' fcrei�r �,"�n hoti� I�n� in �. S.�. ----------yea .rs
<br /> C�3 FULL NAtJ..�F`��:�k �nson Roo
<br /> j. (b) If vetRrax.
<br /> n a_m e �va.r - - - - - - - - �- - - - - - - - -
<br /> �. SPX I�2.ZP.
<br /> 5. Co�or or r?ce ?ahite
<br /> h, (�) Sin:�le, T�.=ido?aed, mar. riFd, divarced M��rried
<br /> 6. (�) iJ�me o� '���u�b��.:.d or ?aif e
<br /> E. � c) A�;e o�' r';�'�'n�. o}'` ?�rife ' '
<br /> ` If alive ---------yr. s.
<br /> 7. Birth d?te c�' dPc��sed. J�,zly 26 1�69
<br /> ( Month) �Day) ��ear)
<br /> �.AG-E: Yea.r�� t�fonths Days If less tha.n onP c�ay
<br /> 7� �1 1Q ------�lr. __ --�"in.
<br /> 9. Birth��.la.c° K��lam�zoo,' . l�lich. ._ _ �
<br /> -
<br /> -- �
<br /> .
<br /> -:� , ,
<br /> . .
<br /> ±� r ?.� � : � Sta.te or farei�n ccantr )
<br /> �� �o .n or c_, .._� � ) ( � Y
<br /> ( i Y
<br /> 3
<br /> ,
<br /> 10. Usu��l oc^un�tion F�rm;ng
<br /> 11. Industr�- or busines��
<br /> FATHE:R t�2.. N�me Ectt�rarG. Root
<br /> �13. Birthpl�ce unkno�,rn Ohio
<br />' City, toTan or county) ( State o �� i oreign c�untry
<br /> MOTHER (��4. Ma,idPn na.r�P L;zcy Palmer
<br />'� (15 Birthplace unkno�an __ Conn.
<br /> ity, to��rn o .r county) ( State ar forei�n countr�
<br />� 16. (a) Inform��nt ' s o?�rn si�;n�t�.are Mrg.Frank Root
<br /> (b) T�1ood RivA,�, Nebr. •
<br /> 1(. (a) �b) Da�e t:��Preof Jui l� 1 �-4
<br /> Bu�^ial, cr�ma.tion or rernoval) (�Iontn) (Day) (Year�
<br /> ( c) Pl��ce :'��?»i�1 or. cr�ra�.tion C��,me��on Cer��terJ, �aooc;. i�iver •
<br /> 1�. (a) �i�;r��t�_zre of f�:�n�^al c�irPctor R. E.Apfel
<br /> (b) Ac�c�ress Wood RivPr. , i�P1�r,
<br /> �9, (�,) JUi�T 21 19��-'� (b) H.A.?�iller .
<br /> ( D�`c� r�ceitreca l�c<�.1 rP�i�tr<=;r) �R��;:�si,r��.r ' � Si�n�ture)
<br /> MEDICAL CFR`I'IF�CATION
<br /> 20. Date of dpa.th� Nbnth June ��ay l j, 19�+�! .
<br /> . . . . . . . . . . . . ncur 11 minute P.�-S.
<br /> . . 55
<br /> r� �b� ��rtif� tha.t I atterided thA ciece��ed �'rom Oct. Zgl�3 �o June 15, 194�-
<br /> 21. I .� .r ,� ,
<br /> J
<br /> th��t I la^t sat�r him �live on June 15, l�4'� ar�d tna.t c�eath occurred on the date and �
<br /> I` hour sta.ted a�ove.
<br /> Immediate c�.��:se of de�th Dur�.tion
<br /> D�zP to
<br /> Due to
<br /> Othe�� c^n��.ifiions
<br /> include �re�� nancs �aitiin ; months o- d�ath)
<br /> � � � �
<br /> t�Ia�jor f�ndin;s : PHYSICI�PJ
<br /> T �
<br />, - z i'
<br /> , ,. r .
<br /> P, .,t1 P, S ,
<br /> Un rlin cau e
<br /> (�f o��e �ati_�n 1`�0 0��?, a.tion de
<br /> I• t�uto;�s;� fi:�cz�n�;�; ��me Y� �.�at�i^looist re�orts. to i�r�ich death snould
<br /> �e charg?d statistically.
<br /> ��, I�' c!a��r,rl T�=a;; due to pX�erna.l causes, fill in �'rie fcl�otiain;;:
<br /> (a ) A�cid.er�t, s��icide, or homicide � s��ecif�r)
<br /> (b) Date o�� occurence
<br /> ( �) '��^�ere di�'� in,jury occur �
<br /> ( City or tc��m ) � Count f) , ( State) �
<br /> ( d) Did in,j�a_ry oc^ur in or ab:�ut nor�°, on �arm, .in indus�ri��l ��la.Ce, in ,�ublic �:l<ce
<br /> ( SpPcify �ype of ��lace)
<br /> ; �,4ni�e ��* �•��,rk ( e) Name of in�j�zry
<br /> 2�. Si�;n?t��re A.J. I�Iol���ahn, M. D.
<br /> AddrQss Waod Rivpr, Date �i�ned 6��7����
<br />' 24, (a) Did t:ie decPased. ha.ve a ;�ocial security nur.nbe-r (b) ��las thP dece�sed. or. ��ny
<br />� mFm'�Pr of ii� immedia..te r��mily r. eceivin� a manth�y ch?ck unc�_e� the Feder•�1 Old-Age
<br /> �nd �u ^vivor� ln�ar«. ,ce Pro�ra.m o� the Sacial �ecurity Boarc�.
<br />' ( c) Dici tr}P c�eceasec� ��t �r.y time since J�.n. l, 1937 ?��orY for an Pm1�loyer in commerce,
<br /> t r�?,C'i P O'^ 1 t1 C�'_Z S t 1';�
<br /> THiS CERiIFI�S �HF A:`30VE TO i-3E A TR'J� COPY OF Ai3 O:rti(xii�IAL CERiIFICATE ON FILE '�iITH THE
<br /> DIVISTGN 0�' VITAL SlATISTICS S�rA`�E DE'�ARTP�IE�1`� OF' HEA�TH,'�JHICH IS THE LEGAL DEFOSITORY FOR
<br /> SA;-4E. ( SEAL) C. �. Se1by M. D
<br /> ST1a1F R�,ulSii--iAR `
<br /> LiNt�OLi�1, NEBRASKA JUI�T 23 19�`�•
<br />' File�� fo:^ rncarc? this 27th c�ay of June, 19��-�, ��t 17_: 15 0 ' �lock ti.M. 0���� �j
<br /> `f��.t�,�„Y_
<br /> egiater of Deeds
<br /> :�-0 .,-0-.^.-7-Ci-0-.^a-0-r;-r-�_0-0-')-7-'�-0-�-=�-^-0-0-0-!�-0-0-0-'�-'``-^-�-0-�-0-0-�-7-,�-^-0-'�-0-
<br /> , AFFIDAVIT
<br /> STATE OF NEBRASKA ) I, Gus �"onrier, being first duly sworn, on my dath depose �,nd say
<br /> COUNTY OF HALL ) ��' that I am a resident of Hall County, Nebraska, and have been such
<br /> for more th��.n 70 years last past; that I am pPrsonally we11 acquainted with the real estate
<br /> described as the Northeast Quarter (NE� ) of section Twenty-ei�ht �2�) in Township Twelve
<br /> �12) North,Range Eleven tll ) , West of the 6th P.M. and tha.t I persona.11y well knew of my
<br /> own kno��ledge, �. P.��.n�e?lg, S.E.Reaugh and Johr� Forner, who are named granteEa in the
<br /> warr�nty deed recorded in Bock Q �.t pa�e 306 in the office of the Register oP Deeds of
<br /> Hall �ounty, Nebraska, and tha.t the Samuel D.Rannells, Samuel E.R�augh and John Fonner
<br /> who were gra,ntors in the deed recorded in Book H at page 7 in the office of the Regis�er
<br /> of D�ed� of H�.11 �ounty, Nebraska, are one and the same persons as the gra.ntePS na.med in
<br /> tne here;nbefore described ?aarranty deed., ir .respective o�' the di�crepar�y in the spelling
<br /> of said n�mes.
<br /> Af�iant furthe�� states that of his o��vn kno��rledge he �aa.s personally well acquainted with
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