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<br /> l�JL� ������ l�l �� �J � ��� ��� V
<br /> 21917—The Auguatine Co., County Supplies, Grand Island, Nebr.
<br /> Arteriosclerosis. Other conditions Cerincious Anemia ( Tnn� �?c�.e pregnancy within three .
<br /> months of de�.th) Duration l�+ day5. Ma,,�or findings: Of �per��ions
<br /> Of autopsy
<br /> PHY��ICIAN Underline the cause to which death should be charged statistically.
<br /> 22. If death was due to extern<�.l cau5es, fill in the following:
<br /> ( a) Accident, suic3.de ar �omicide ( specify)
<br /> (b) Da�e or occurrence
<br /> ( c) ��'here did in,�ury occur
<br />' City or toUrn County State
<br /> ( d) Did ir,,jury occur in or a.bou� home, on �. farm, in industrial place, in public
<br /> pl�ce
<br /> Specify type of p12ce
<br /> � ?�lhile at Urork ( e) 2'leans of in3ury
<br /> 23. Signature L.E. E�en ( M. D. or other)
<br /> Ad��ress Hastings, Nebr�ska Date signed 10I29I�1 ,
<br /> This is to certify that the above is a true and cor-rect copy oP the original
<br /> certificate iorwarcled from my of�ice to th� department of Vital Statistics, State of
<br /> Nebraska.
<br /> � Dated. at Ha.stings, Adams County, Nebras'_�a, this 3 aay of August 194�.
<br /> ( SEAL) Edwarc� L. De er
<br /> Ci ty Cl erk
<br /> ` Filed for recor�, this 1 da.y of November, 19�I-4 at 2: 30 o ' clock P.bl. � ��/�.-�/d�
<br /> ��
<br /> Re�ter of ee s —
<br /> o-o-o-c-o_c-o-o-o-o-c-o-o-o-o-o-o-o_o-�-o-o-o-o-o-a-o-�-o-o-o-o-o-o-c-o-o-a_o-o-o-o-o_o-o
<br /> CERTIFICATE OF DEAmH �
<br /> STA'?'E 0�' TJEBRASKA
<br /> Bureau of Hea_lth-Division of
<br /> Vital St�tistics L 5115
<br /> Cr RTI�'I CATE OF DEATH
<br /> l. Co�antsr Ha11
<br /> Township
<br /> City Gr�nd Isla.nd 1�?0. 60� Street '�T 9t'rl (If deat'r� occurred in a hos�ital or
<br /> in�tit;ution �ive its NAP�:�' inste�.d of street anc�. r�umber)
<br /> 2. Full Name Sarah Louisa Hendricks H-536
<br /> Res3dence Granc� Island PJebr.
<br /> PERSO^,?AL A?V� STATISTICAL ?'�1RT?C'JL�RS
<br /> �. Sex Female
<br /> . Color or Race �ti�l�ite
<br /> J. S�n"le, P��arried, t�lic�.ot�red, Divoreed (Wr�te the ��ord) ��didoc��
<br /> (a) . If marrie�., �w��ic�oTred or d�vorced �iu�band of
<br /> or
<br /> '��ife of ��J.H.Hendricks.
<br /> 6. Date of Birt'r� (ma) Dec ( d�,,:T) 1�- ( yr. ) 1�4g .
<br /> Z 7. A�e Years 90 P��Ionths � Days 21 If less than 1 day Hrs or. P�fin.
<br /> � �. Trade, profession or p�.rticular �.ind of ��rork done; as spir.ner, sawyer, bookkeeper,
<br /> � etC. HOUS2ttr�fe
<br /> a 9. Industry or busir�ess in whic� t�ork was done as silk �:�ill, saw mill, bank, etc
<br /> b 10. �a�e dece�sed last t��orked at tnis occu��.tion (montn and year)
<br /> 11. Total. �ime (ye��.rs) s��ent in this occupation
<br /> 12. Birtr_place � Cit,y or to��rn and State or country} U. S.
<br /> 13. I�;�,me of Fat�'`1P,1' EliC a Levee.
<br /> l��-. Birth��lace o#' Father ( C3ty or toT�m ana �tate or co��?n�ry) N.Y.
<br /> 1 J. Maiden n��ne of Mot�2er Ly�ia. �covill.
<br /> 16. Birt'r�place af i�loth�r ( Citv or to.-rn �ncti State or cauntry; N.Y.
<br /> l7. Inform�nt (Address) Alfrec� �ehrens Grarid Tsl�.nc�
<br /> l�. Burial., creination, or removal
<br /> Pl�.ce ??hillips, ��Te�r. D��.te �_� �
<br /> lo. Uncert�,ker Geddes Funeral Home
<br /> (Ad�:�^es�) Gra..nd Is7_and, Ne'�r.
<br /> 20. P�"ay 1�-, 1���0 F. S. r�hit e Re�is tr�nr.
<br /> It���DICAL CERTIFICATE OF DEATH
<br /> 21. Date of Dea.th P�1a.Y 5, 1a40. �
<br /> 2?. I �es�eby certify, that I attencted dece�sed irom ?�ay 5, 1�40 to May 5, 19�+0. I last
<br /> saz�r r.er al.ive on I�7ay 5, �.�=%��0, c�eat�z is s�id to h�ve occ��rred on the date stated �.bove,
<br /> a� 5: !�5 P.r.2.
<br /> Thp x�rincipa,l ca.use of death ana related c��.uses of im7�ortance in p7'c�GY' of onset t�rere
<br /> as �'ollo�ti�s : �
<br /> Ar. tei�ial Sclero�is D�,te oi Onset ��
<br /> Cle�'o>>i� r�'Iy01.�rC�1t1.0 �_��� .
<br /> Contrib�atory c^uses of im��or�ance not rel�ted to principal causes :
<br /> NamF of' Oper�.tion �`a,te oi
<br /> r�that test c;o:.1'�a_�r�ie�.i diagnosis? Ex�.m. ��das there an a.utc��sy?
<br /> 23. If de�t�l �.�ra.s aue to e�t�rn�al cau�es (violence} fill �.n also t�ie folloUrin�: Accident,
<br /> suici��P, or nomicide Date of in,�ury , l; .
<br /> ��There cl�d ir�jury occur� (S�,eci�'y cit;� cr to��rn, county, and State)
<br /> Stiecify !tiLietner injury occurrEd ir: Inclustry, irz �.o��:e, or i:i public place.
<br /> Manner o#' in�ury N�.tLa2�e of Irl,jury
<br /> 2�-. frv'�s disease or �njury in a,n;� ti�r��;T rela.ted to occ?�p?�=i-cn af d.eceasec�? No. Tf' so,
<br /> :�r�eci-�'y. i�lor�e �
<br /> ( Sivrieci.) ��T. D.l�.cGrath� r<l. D.
<br /> � (Ad;:_r�ss) Gr��nd Island, :�ebr.
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