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<br /> ��Jl� �� ���� l�l �� �J � ��� ��� �J
<br /> 21917—The Auguatine Co., County Suppliea, Grand Island, Neba � �
<br /> 7. Birth d�te of dece�,sed (rno. , d�.y, yr, ) . . . .Fe'�. 12, 1�92.
<br /> �'. A�;e. . . 52 Yea.rs, 9 r�ionths, � i��ys. (If less than 1 da� . . • .hrs. . . . .min. )
<br /> 9. Birthplace. . . . .Om�ha, iJebraska
<br /> (Town, count� �znc� s�ate or foreign country)
<br /> 10. Usual Occ�apation. . . . .Ra.ilroa,d rate clerk.
<br /> 11. Industry or busir:ess. . . . . . .-. -. . . . . . . .
<br /> 12. FATHER:
<br /> P�a.me. . . . . Ernmett (or Em:Ll) Johnson
<br /> 13. BIRT�-�PLACE:
<br /> City, town or country - - - - Stzte or forei�n country. . . . . Sweden
<br /> l�. P�•�OTHER:
<br /> i�ame. . . . .Amelia, -- Jollnson
<br /> 15. BI�-tTHPLACE:
<br /> City, tos��n or country - - - - State or foreign country. . . . . S?,reden
<br /> 16. Informant � s oT�m si;nature. . . . . (Hospltal Records) (a)
<br /> (b) Adcress. . . . . V. A. Knoxville, IoiRra.
<br /> 17. (�,) Buri�.l, creniation, or removal (specify) . . . . . ret�oval
<br /> (b) Date thereof. . . . . . . 10-20-4�- (24onth - J�_y - Year�
<br /> (c) Pl��ce of BuriC 1 or Creina.tion. . . . . Boc�y shi,�pe� to L:incoln, Nebr.
<br /> 1�. FUP�IERAL �IRECTOR:
<br /> (a) "i�nature. . . .All.en'.P. Bybee
<br /> (b) Ad,clress. . . . . .Knoxville ( c) License No. 1057
<br /> 19. LOCAL RFGSSTRAR:
<br /> �i�natu?�e. . . . .Gene P�,rker District. . . . . 63-2
<br /> i<te received 11/25/�-�- Filen No. 163
<br /> 1'iELI CAL CERTI FI�ATI Oi�?
<br /> 20. �Ai� 0�' iEATH. . . . . PJoveln'aer 20, 19�F��. . . . . . �,t :00 A. Z-�.
<br /> (T�Iont�i-?•1RIiE GT1T- �'��y) ��ir.�e)
<br /> 21. I CERTIFY tha� c:te�.th oecurrea on t��e date Li(JO�r2 st��.ted; that I atter�cied dece�,sed
<br /> fro�� August 27, 1°�-2 �o Tlovember 20, 1�44, an� t'ri�,t I saw him alive on Pdoveniber 20,
<br /> 19�+4. Ir.ir�ediate Cause of Ge�th. . . .VIII-10�(ILCD) Termina.l 1ob�r pneur�onia
<br /> �ura.tion of conci-_�io�z. . . . . . . ? L��;;rs .
<br /> y�v.e to
<br /> p�Yier conc�itions :
<br /> VII-9�+ (a) (ILCD) Ar�eriosclerosis of coronar;� �:�rtery
<br /> (Prior to admission)
<br /> XVI-Z62(�,} (ILCD) Setlile psychosis
<br /> (Prioi^ to �tiai:�ission)
<br /> (Inclucle nre�;nancy r�ithin 3 nonths of cteath)
<br /> Over�.tion: D�te of -----
<br /> I�AJOR � Of Ox�erC tion - - - - - Of au�:opsy- -
<br /> FII�'�Ia��GS) - - + -
<br /> (Physiciarz - Ple<<:,se underline tne cause to t��rYiicn the deatn should
<br /> :�e ascribed. )
<br /> 22. IT" ex�ernal, caus es c�?ntribut ed to the deatn, f3.11 in the follot�,ino:
<br /> ACCIDEiv'T - SL'ICIDE -- HOt-IICIDE
<br /> (a,) . . . . . . . . . . . . . . . . . . . . . (b) D�te of. . . . . . . . . . . ( c) '6'here di� in ury occur. . . . . .
<br /> (Acciclent, suicic�e or hoMicide) ( City, totian) � County) (State)
<br /> (d} In,jured �..t home, fa.,rm, inczustry, pu'�lic pla.ce, (ti•rhere) . . . . .
<br /> (e) Injurec? at i�.rork (yes or no) . . . . . . . . . .
<br /> (f) r�2e�.ns of in,j ury. . . . . . . . . .
<br /> {�) I�'ature of In�ury. . . . . . . . .
<br /> 23. (a) Si��nature. . . . . . . .A. �. Y'Tooas. . . . .Lit�ensed TZ. D.
<br /> � (b) A:ciress. . . . . . . . .VetPrar�s A��rninistratio�, Krzoxville, Ioiaa.
<br /> (c) ��.te Si�ned. . . TJovember �0, lg��-.
<br /> SOCIAL SECUF,ITY ACCOUNT i�:0. 7U7-07-0963
<br /> I ?�FREBY G'�TIFY th�t this is �. true �nd correct copy, ma.de of the
<br /> original certific�tite noT�r on file in this office in accorc�.ance *.�rith the lat�r of Ioc��a re-
<br /> quiri,�ng filin� of `Tit�.l Recorc�s.
<br /> ?�1��,1 t er S, Bi enin6i T�.D.
<br /> DATE Au�. 5, �.g46. Ioi-�a St�te Re�;istrax
<br /> (�SEAL)
<br /> L. E. Chancella.r
<br /> Acting�;Director, �ivision of Vital Statistics.
<br /> Filec� for record the 9t'ri �.a;� of August, 1��-6, at 1:15 0 � clock P.P�i. "�
<br /> ��;�� �
<br /> Re�ister of eeds
<br /> 80�0-0-0-0-0-0-0-0-0-0-0-0-0-0-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-
<br /> RIGriT OF 1!'�AY LEj'�SE
<br /> Aud�� T?o. - - - - - - - Div. l?o. - - - - - - - Land Dept. Pd. T:i 41200
<br /> RIG�iT OF GVAY L���E
<br /> '?T'IOi�' P1�CIFI� : .�II1ROr�D CG,.iPAa'Y �7.ei�eby leases to Florence Am�li�. Johnson jOj East 4th
<br /> Street (an abut�ti�z� 1:�nd ot�rner) o� Gr<<znd Island, Hall County, TJebras�.a, �or a period of
<br /> trrenty years �'rom June I jtii, 1��6, (unless sooner t:�rminatec� in accordAnce �vitlz t�ie terms
<br /> hereof, � , a portion o' 3.Ls �F00 foot ri�;►it o� F�ay in Hal7_ County, T?ebrasl�.a, to be used �°or
<br /> a�;ricultural nurposes onl�r, descri�ed as �'olloiTS:
<br /> All ��:at na,rt o� ��ze P1ortl�.t�est C�uarl�er (N�74) o�' 5ection TlZirty-fbur (3�}) , in To�rnslzip
<br /> Eleven (lI_) Nort11, of Ran�;e ien (10) �Vest o�' fille Sixtl� (6tt1) princif�al ?'.ieridian, �allich
<br /> is incllzded bert�e�n lines parallel Evitl_z and dist�.nt respectivelv, Sixty-�oui� (64) feet
<br /> ana T�°ro hundred ( �00)feet, at ri�ht an�les ;rom �d'�on the Nort}lerly s3.de of tile center
<br /> line o� t`:e soufh r��.�.n �ract of the Lessor, as sa�d trac�. i5_ constructed aa�.d operated
<br /> over and ac-ross said Section Tlzirt4r-�°our (�4) .
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