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���' S R�CORD V <br /> I�IISCELI�ANEOU <br /> � <br /> 2905B-TNEAUGOBTINEC0.6PANUISLAND.NEBR. . I� <br /> � <br /> CERTTFICA�E OF DEATH <br /> �e�artmer�t of Commerce THE STATF BOARD OF HEALTH OF MIBSOURI <br /> u eau o thF-Census 5TANDARD CERTIFICATE OF DEAT�i state File No. 9230 <br /> Registration District N�. 14�3 Registrar� s No. I2 <br /> FILED APR 1.� 1946 Primary Registration District No.5�60 �232 <br /> 1. I'LACE OF DEA3'H i <br /> (a) County Howell <br /> (b) City or tow n Willow Springs <br /> (e) Name of hospital. or institt�tion: Home <br /> (d) Length of stay: In hospit��,l or institution ----- <br /> In �h3.s community 10 years <br /> 2. U5UAL RESIDENCE OF DECEASED: <br /> (a) S�ate Miasou�°1 <br /> (b) County Howe11 <br /> (d} City or town Wi11ow �prings <br /> (d) �treet No. ---------------- <br /> (e) Citizen of foreign country? No. <br /> 3, (a) PRINT FULL NAME- Fred H. N3.emoth <br /> 3. (b) If vet�ran, name war ---- <br /> 3. (c) Social 5e�uri�y No. ---- - <br /> 4. Sex Male <br />' S. Color or race White <br /> 6. (a) �ingl�, widowed, married, divorced �idowed <br /> b. (b) Name of husband or wif� ------ <br /> 6. (c) Age of husband or wife if al.ive -------- years. . <br /> 7. Birth date of deceased. Ju1y 23, �.877• <br /> 8. AGE. Years Months Days Tf lesa than one day <br /> 68 7 1�' ----hr. ------min. <br /> 9. Birthplace Grand Island, Nebraska.. <br /> I0. Ugual occupation Farmer <br /> 11. Tndustry or busines� Retired Farmer <br /> FATHER <br /> 12. Nam� John Niemoth <br /> ��. B�.rthplace Ea�t Prussia <br /> MOTHER <br /> 14. Maiden name �Wilhelmia Linstedt <br /> 15. Hirthplace Pomerania <br /> 16. (a) Inf ormant T. W. Niemoth <br /> (b) Address Grand I51and, Nebr. <br /> 17. (a) Hurial � <br /> Burial,cremation,or removal) (b) Date thereof 3/13,�46 <br /> (Month) (Day) (Year) <br /> (e) Place burial or crema'�ion Pine Grove Cernetery _ <br /> 18. (a) Signatlzre of funeral director Hurne Funeral Hom�a <br /> (b) Address Wi].].ow Sprin�s, Misaouri <br /> 19. (a) (Date received local. registrar) 3-11-1�6 <br /> (b) (Re�istra'�' s s3.gnatur�) Ila McMillen <br /> MEDICAL CERTIFICATION . . <br /> 20. DATE �F DEATH: Month Mareh day lOth year 1946 hour Approx. 1:30 A.M. <br /> 21. I hereby csrtify that I a�tended the deeeased from --------19---, �o --------,19, <br /> that I last saw h-- alive on ----------19---; and t�hat death oecurred on the date and <br /> hour sta�ed above. <br /> Tmmediate cause of death Cerebra3. Haemorrhage Duration----- <br /> Due to------- <br /> Due to------ , <br /> O�her canditions (include pregnancy within 3 months of dea�h) <br /> Ma�or findings: PHYSICTAN <br /> Of operat9.on 8�A Underline the eause <br /> Of autopsy � to which death should <br /> be charged statiqtical,3.y. <br /> 22. T� death was due to external e�uses,fill in the following: - <br /> (a) Accident, suicide, or homicide (specify) <br /> (b� Date of occurrence Mareh 10, 191�6 <br /> (c) Where did in,�ury occur? Horne <br /> (d) �id in,�ury aecur in or abou� home, �n farm, in industrial place, in }�ublic place? <br /> Whil e at i,�ork?`: (e) Means of in�ury--------- <br /> . <br />'� 23. 3ignature Mayme C. Thornburgh Coroner <br /> Address t�Fest Plains, Missouri, ,Date �igned 3/12/�6 <br /> (Licensed Embalmer' s Sta�ement on Reverse 8ide) <br /> STAT� OF MISSOURI ) <br /> CITY OF JEFFERSON ) ss' I HFREBY CERTIFY that the above is a true and correct copy of th� <br /> t or the erson named therein. The ori inal record bein filed in 'Ghe Cen�ral, <br /> certifica e f g <br /> P g <br /> Bureau of Vital �tatistics of the State of Missouri is part of the permanent records of <br /> said bureau. WTTNE�S my hand as State Regi�'�rar c�f Vltal Sta�is�ias a.nd the Seal of the <br /> Missouri State Hoard of Health this date of May 3, 1946. <br /> (SEAL) R. M. James M.D. <br /> ( STAT� DEPARTMENT OF)� � -�tats Registrar of Vita1 Statis�ics. <br /> ( HEALTH ) Per Loretta Erhardt. <br /> ( S E A L ) <br /> Fi1ed f or record this 2 day of June 194�7, at �:4�5 o' cloek P.M. ' ^ <br /> /J / �4 <br /> <.J(.�����-L( `../��-�-�� f� <br /> Register of Deeds <br /> , 0-0-0-0-0-0-Q-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-Q-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-Q-0-0-0-0- <br /> L _--- --- 1-- <br />
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