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��� <br /> �1LV� ���� 1�1 �� �.J � ��� ��� �.J <br /> 21917—The Auguatine Co., County Bupplies, Grand Island, Nebr. <br /> Subscribed in my presence and s�orn to be�ore me, tYie underaigned a Notary Publlc ln and <br /> Yor said County and State above named, this 27 day o� November,l9�5. <br /> A�y General Commiaeion Expipes July 1�+,19�� (8�� L.T.Osborn <br /> Notary Public <br /> State o� Nebraska � - <br /> )SS BePore me,a Notary Public in and Por said County and S'�ate, <br /> Hall County ) on this 27 day oY November,1945,peraonally appeared Avnelle <br /> L.Lauer,to me �nown to be the identical person who executed <br /> the within and Poregoing instrument,and acknowled�ed to me that she executed the same as <br /> I her �'ree ancl voluntary act and deed,and Yor the uaes and purpasea therein set �orth. <br />' WITNESS MY HAND and seal the day and date laet above z�a,med. <br /> . L.T.Osborn <br /> My� commission expires: Notary Public <br /> Filed �or record thla 11 day oY January,19�+5,a� 10:30 o'clock A.M. ������ <br /> Register oP Deeds <br /> -o-o-a-o-o-o-o-o-o-o-o-o�-o-o-o-o-o-o-o-o-o-v-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o <br /> CERTIFICATE OF DEATH <br /> NEBRASKA (STATE) DEPARTM�'NT OF HEALTH <br /> Division of Vital Statistics � <br /> 3�A NDARD� CERTIFICATE OF DEATH. <br /> I��PARTMENT OF COM2=4ERCE <br /> BUREAtT OF' THE CENSUS Social Security No. ------ State File No. <br /> . A 0F EA . <br /> (a) County Dat�rson <br /> (b} City or town Lexingron <br /> (c) Name o� hos�oital or institution <br /> -6oi E.13 tn . _ _ . . . _ . ._ ._ . <br /> f' ndt in hospital or institution, write street number or location <br /> (d) Len�th of stay : In hospital or institution <br /> In this community 6 months <br /> pecify whether yrs.mos, or days. <br /> 2. USUAL RESIDENCE OF DECEASED <br /> �a) State Neb. (b) County Dawson <br /> (c) City or toz�rn Lexington <br /> (d) Street No. 601 E.13th <br /> (e� IP foreign born, how long in U. S.A. - -----yrs. <br /> 3 (a) FULL NAME Theresa Anna Hastings <br /> � (b) If veteran, na.me war. � <br /> . �ex Female <br /> 5. Color or Race White <br /> 6 (a) Single, widowed, maxried, divorced- married. <br /> � (b) Name of husband or wife - Frank Hastings <br /> 6 (c) Age of husband or �rife, if alive <br /> 7. Birth date of deceased August 2nd, 1F�9�- <br /> �. AGE: Years Months Days I�` less than one day <br /> 51 3 � ---hr. ------Min. <br /> 9. Birth�lace Indianola, Nebraska <br /> 10. Usual occupation Housewife <br /> 11. Industry or business ----- . <br /> Father <br /> 1 ame enry . olling <br /> 13.Birthplace �pringfield, Illinois <br /> Mother . <br /> . a den name nna rcher <br /> l5. Birthplace GPrmany <br /> l�� -ln�'ormant s o��rn signature F. E.Hastings <br /> Addr ess Lexington, Nebr. <br /> 17. Ga : t��ri�.l, crematio , or removal) <br /> (b� Date thereof ll�l0/19�5 <br /> (c) Place; burial or cremation Lincoln, Neb. <br /> 1�, (a) signature of funeral director Chapman Hiybf , Mort. <br /> (b) Address Aurora, Neb. <br /> 19. (a) �.1-��--�+5 <br /> Date received local registrar _ <br /> (b) W.R.E�inberger <br /> (Re�istrar' s Signature) <br /> MEDICAL CERTIFICATION � <br /> _. .20. Date of death: Month Nov. day 10 �9�+5 <br /> 6 hour 15 minute A.M. <br /> 21. I hereby certify that I attended the deceasEd from 10--�-�5 <br /> to 11-10, �9�+5, that I last saw her alive on 11-10 19�+5, and <br /> that death occurred on the date and hour stated above. <br /> Immedia,te cause o� death Du��t�n <br /> Ventoriula pelli�ilia.t�.on <br /> Due to <br /> Due to Cse of C3v�.ry� pH�SiCIAN Underli�e the caus to <br /> Other Conditions w�.i�}� ��at� should be charge� <br /> Ma,jor findin�s s�a s ca ly. <br /> 4f operation Cs� Q4ar.3ar�� -�rith milati�I�s genera�. <br /> 4f Autopsy <br /> 22. If death was due to external causes, fill �n the following: <br /> (a� Aecident, suicide, or homic�.de (spec,�fy) <br /> (b) Date of oecurence . <br /> ( c) Where did in,�ury occur <br /> (City or �totian) ( County) (State) <br />