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<br /> 21917—The Augustlne Co., County Supplies, Grand Island, Nebr.
<br /> CEP.TIFICATE OF DEATH
<br /> NEBRASKA (STATE) DEPARTMENT OF HEALTH
<br /> Division of Vital Statistics
<br /> STANDARD CERTIFICATE OF DEATH
<br /> Department of Commerce y State File No.N10�67
<br /> Bureau of tlie Ceneus Social Securit No.
<br /> �. PLACE OF DEATH
<br /> (a) County H2till �
<br /> (b) Cit,y or town Cairo Nebr. �I.f outsicte city er tr�T�n lim�.ts,tarite RURAL. )
<br /> ( cl N�me of hpspit�l oi �nstitution;
<br /> , _ . : �,
<br /> f if not in hos��ita1 o,r institut�.crn ta�'ite str�et number of location)
<br /> �d) Length of stay: In hospital ar institution ��pecify i�rhether) .
<br /> In this community 57 yea.rs (years months or days)
<br /> 2. USUAL RESIDETdCE OF DECEASED:
<br /> (a) State Nebraska (b) County Hall
<br /> ( c) City or town Cairo (If outside city or toTan limits, write RURAL
<br /> (d) Street No. (If rural give location)
<br /> (e) If forei�n born, not�r long in U. S.A. ----- years
<br /> 3 (a) FULL NAME James Edward Orndoff
<br /> �• (b) If vet eran, name war o-653
<br /> S ex M
<br /> 5. Color or race w.
<br /> 6(a) singl e, �aidowed,married, clivorced Married.
<br /> 6. (b) Name of husband or wif'e Lillie Orndoff
<br /> 6. (c) A�e of husband or wife, if �live 71 years.
<br /> 7. Birth date of deceased June 14 1�52
<br /> (Month) (Day) (Year)
<br /> �. AGE: Years 90 ,Months 5, Days 11 . If less than one day ---hr. ---min.
<br /> 9. Birthplace Edinburg W.Va.
<br /> (City, tos�m, or county) (State of foreign country�
<br /> 10. Usual occupation Retired Farmer
<br /> 11. Industry or business
<br /> Father
<br /> 12. Name Robert Orndoff
<br /> 13.Birthplace Unknozan _
<br /> Mother �ii�y o�wn or county tate or fore��n : country)
<br /> l�. Maiden Name Unknown
<br /> 15. Birthplace Unknown
<br /> (City, Town or county) (State or foreign country )
<br /> 16. (a) Tnformant�s oTr.m signature John Orndoff
<br /> (b) Addr ess Ravenna, Nebr.
<br /> 17. (a) Burial (b) Date thereof Nov. 2�, �42
<br /> uria , cremation or removal) (Month) (Day) (Year)
<br /> (c) Place: burial or cremation Cairo, Nebr.
<br /> 1�. (a) Signature of funeral director J.G.Love �
<br /> (b) Addr ess, Ravenna, Nebr.
<br /> 19. (a) Date recorded loca.l registrar. 11-29-�2
<br /> (b) Registrar� s signature F.w.Moore
<br /> MEDICAL CERTIFICATION.
<br /> P(�. Date of death: Month Nov. day 25 19�2.
<br /> --�--hour--A:�4:- miriut'e 30
<br /> 21. I hereby certify that I attended the deceased from 1935 to Nov. 25, 19�2
<br /> that I last saw him alive on Nov. 24, 1942 and tnat death occurred on the date and
<br /> hour sta.ted above.
<br /> immediate cause of death myocarditis Dura.tion 7 years.
<br /> Due to
<br /> Due to -
<br /> � Other canditions
<br /> (Indicate x�regnancy �rithin 3 montns of death.
<br /> Ma,jor f incl.in�s:
<br /> Of operations ------( PHYSICIAN Underline the ca.use which death should be )
<br /> Of autopsy ( charged statistically. )
<br /> 22. If death w as due to external causes, fill in the following:
<br /> �a) Accident, suicide, or homicide (apecify)
<br /> (b D�te of occurrence
<br /> ( c Where d3.d in,jury occur
<br /> ( City or town ) (County) (3tate}
<br /> (d) Did in,jury occur in or a.bout h�me, on farM, in industrial place, in public place
<br /> 1 ce -
<br /> t ��e of � a
<br /> s ecif )
<br /> � U Y± _
<br /> Y
<br /> While at work � e) Means of in,jury
<br /> 23. Signa_ture M.R.Piersol (M.D. o�� other)
<br /> Address Cairo, Nebr. Date signed Nov. 30, �2.
<br /> TO BE ACCOMPLISHED T�iEN BODY I� EMBALMFD
<br /> 2�. I hereby certify I peracnally embalmed the body of the deceased n�,med hereon.
<br /> J.Filmore Love
<br /> License No. 1174
<br /> THIS CERTIFIES T�E ABOVE TO BE A '`�'RUE COPY OF AN OR2GINAL C ERTIFICATE ON FILE WITH THE
<br /> STATE DEPARTMENI OF HEALTH,BUREAU OF VITAL STATISTICS,WHICH IS THE LEGAL DEPOSITORY FOR
<br /> VTTAL RECORDS.
<br /> C.A.Selby,M.D.
<br /> DIRECTOR- OF HEALTH AND BUREAU OF VITAL
<br /> STATISTICS,
<br /> LINCOLN, NEBRASKA, �iov. 10, 1945
<br /> Filed for record this 13th aay of November, 19�+5, at 9t 15 0 � clock A.M. y` �
<br /> e�ister o�f' D�eds
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