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<br /> �1I� S��EL�L�.�T���J� ��EC ��� �.7
<br /> 21817—The Augustine Co., County BupPliea, Grand Island, Nebr.
<br /> (d) Did in,jury occur in or about home, or farm, induatrial place, in public place
<br /> (Specify, tyne of place)
<br /> While at work (e) r��eans of in,�ury
<br /> 23. Signature M.J.Ayres (M:D. )
<br /> Address Lexington, Nebr. Date signed 11-14-�+5
<br /> �'0 BE ACCOMPLI SHED ZaFi�N BODY I3 EMBALMED.
<br /> 25. I hereby cer�tify I personally embalmed the body of the deceased named hexeon.
<br /> Eldon E.Higby License No. 17�-1
<br /> THIS CERTIFIES THE ABOVE TO BE A TRUE COPY OF AN ORIGINAL CERTIFICATE ON FILE WITH THE STATE
<br /> I DII'ARTMENT OF HEALTH, B[7REAU OF VITAL STATISTICS, WHICH I� THE LEGAL DEPOSITORY FOR VITAL
<br /> RECORD3.
<br /> C.A. Selb M.D.
<br /> I ��� D RECTOR OF HEALTH AND BUREAU
<br /> OF VITAL STATISTICS,LINCOLN,
<br /> NEBAASKA.. Dec. 6 1 45
<br /> F'iled for record this 15 day of January, 19�-6, at �:00 0 � clock P.M. � _
<br /> egis er of e e�
<br /> 0-0-�-0-0-0-0-�-0-0-0-0=0=0-0-0-0-0-0-�-0-0-0-0-0-0-0-0-0-0-0-0-0-(�-0-0-0-0-0-0-0-0-0-0-0-
<br /> AFFIDAVIT
<br /> STATE OF PtE£�RASKA, )
<br /> ) ss. AFb'IADVIT
<br />' HALL LOUPdTY ) �
<br /> i
<br /> Grover C.Raven,being first duly sworn,u�on oath deposea and says that he is personally
<br /> acquainted vritkl Sarah Cox,a �;randchild of Christian Jacobsen,and that l�e ia personally
<br /> acquainted wltt� Sarah Cox Thompson,who,wi�h her husband,Rollin Thompson,�,� qu3t-clal.m deed
<br /> ina Town o
<br /> t r t in Lot 2 Block 1 0� the Ori 1 P
<br /> F on e
<br /> d their in e ea , 7 �
<br /> c ve
<br /> dated ebruary 7,1�39, Y
<br /> Cairo,Hall County,Nebras�:a,�o Tena Jacobaen Cox,That the said Sar a h Cox and '�he �a i d Sar a h
<br /> Cox T�om san is one and t he same person,no t�+r i t hs t andi n g the discre panc y in nar�es.
<br /> P
<br /> A�'�iant turtk�er states that he ie peraonally ac�uainted wi't�i Helen Cox,a �randchild o�
<br /> Christian Jacobsen,and that he is peraonally acquainted with Helen Cox Roney,who,with her
<br /> husband, Clyde H.Roney,by quit claim deed dated February 7,1g39,conveyed the3r inter�st in
<br /> Lot 2,Block 17 0� the Ori�inal Town o� �airo,Hall County,Nebras�a, to Tena Jacobaen Cox.
<br /> That the said Hele� Cox,and the s�id Helen Cox Aoney, is one and tlie same person,not�ith-
<br /> standin� the discrepancy in nr�r�es.
<br /> Grover C.Raven
<br /> Subscribed in my presence and sworn to be�'ore me on this 1�F c�ay ot' January,1946. �
<br /> ( SEAL) �.E.Sorenaen
<br /> Commisaion expires July 20,19�+9 Notary �Public
<br /> �'iled Por record this 16 day o� January,l9�6,at � o'clock A.�I. ''� ��,��..� �
<br /> Re�ai ter of Deeda
<br /> -o-o-o-o-o-o-o-o--o-o-o-o-o-o-o_o-o-o-o-o-o-o--o-a-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) DEPARTMENT OF HEALTH
<br /> Divis�.on o?' Vital Statistics .
<br /> STANDARD CERTIFICATE OF DEATH.
<br /> BEPARThSENT OF COMMERCE
<br /> BUREAU OF T�-3E CETISUS Socia,l. Security No. State File No. R762I
<br /> l. PLACE OF DEATH: -
<br /> (a) County Hall
<br /> (b) City or to�tim Grand Island,
<br /> ( c) Name of hospital or institution .
<br /> 237 s• s;�camore St.
<br /> T�not in ha�spital or institution, write street number or location�
<br /> (d) Length of stay: In hbspi�al or institution _
<br /> Zn tnis community 1 yr.
<br /> (Specify whether yrs,mos or d.ays) -
<br /> 2. USUAL RESIDEr?CE OF DECEASED.
<br /> (a) State Nebr. (b) County Hall
<br /> ( c) City or town Grand Island -
<br /> (d) Street No. 237 S. Sycamore
<br /> ( e) If foreign born, how long in U. S.A. ------yrs.
<br /> 3. (a) FULL NAME James Hibbs
<br /> 3. (b) Zf veteran, name war --- -
<br /> 1�. Sex Male
<br /> 5. Color or race White
<br /> 6. (a) Single, ��idowed, married, divoreed -�ar.
<br /> 6 (b) Nar�e of husband or �ife Tillie--
<br /> 6. (c) Age o f hu sband or �ai f e, if aliv e ----yrs. � -
<br /> 7. Birth d�te of deceased Feb. 2, 1��7
<br /> �. AGE: Years 5� Months -6 Days 1 -
<br /> g. Birthplace Sa�aboxzr.n, IoU�a
<br /> 10. Usual occupation -- --
<br /> 11. Industry or business Retired Farmer
<br /> FATHER
<br /> 12. 1�ame �amuel Hibbs
<br /> 13. Hirthplace U. S.
<br /> MOTHER
<br /> 14. �aiI— den name Emily Bucher
<br /> 15. Birthplace U. S.
<br /> 16. (a) �,nformant� s orfan si�nature Mrs. Ja,mes Hibbs
<br /> (b) rand Island, Nebr. •
<br /> 17. (a) Bur�.al, cremation or removal) Burial
<br /> (b) D ate thereof Aug, 5, 19�+5
<br /> (c) Plaee: burial or cremation Elwood, Nebr.
<br />
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