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<br /> NII�CEI�LAN�OUS �2ECORD V
<br /> 29088-TN[IIUGOiTINECO.GRANDIfLAND.NECR. � �
<br /> STATE CF Nebras?�a) On triis 22nd day of Decer�ber, A. D. 19t�7, before me, the under-
<br /> ss. �igned Rose P. Dudek a Pdotar,y Public, duly co�missioned and
<br /> Ha.11 Co�.znty ) q_ualified for ar.d residin� in said c�unty, persanally c�Me
<br /> Alice F. Lar.g�n �nd Frederic'_�: J. Langan to me known to be the
<br />� identica.l ��ersons whose nar:;es are �ffixed tc the fcregoing in�trument and ackno�rledge� the
<br /> sar�e to be their voluntarv act and deed.
<br /> ���Titness my ha.nc� an�. Not�,rial Seal the day and year last above written:
<br /> �ose P. Dudek
<br /> - (SEAL) Notary Public.
<br /> ��'y Commissio�� expires the llth das� of �ebruary, 1952..
<br /> STATE OF :�ebr. )
<br /> SS. On this 31 d�.y of Dec.A.D. 19�7, before me, the undersigned
<br /> County of Lanc�ster) Otto H. Schmidt, a Not�ry Public, duly commissioned ana. qual�.fied
<br /> for and residjng in sai� county, nersonally came Florence
<br /> Dra.in Rubt,r and Dor.ovan N. Ruby, H�asband �r�d ?�?ife to me known te be tc�e identica.l persons
<br /> ��nose rlames affixed to the foregoing i.nstrument and a.c�notaledged tne sar�e to be our voluntary
<br /> act and deed.
<br /> WITPdE�S my h�.nd ar:d Notarial Seal the day anc� year l��t above writ�en.
<br /> Otto H. Schmidt
<br /> (SEAL) Not�ry Public.
<br /> P�Iy Cor�mission expires the 30 da.y af Aug. 1��+Q. , �
<br /> Filed for record the 26 day of January, A.D. 19�� at 11: �5 o ' cloc}� A.M.
<br /> eg ster of ee�
<br /> 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-e-o-o-o-o-o-a-o-o-o-o-o-o-o-o-o-o-o-o-o
<br /> DEATH CExmIFICATE h
<br /> Dr. Carl P�?a�giori
<br /> STATE OF NEBRA�KA
<br />� DEPARTr?�''�T OF H�ALTH �
<br /> Burea.0 of Vital Statistics
<br /> STA^'DA�.D CERTIDICATE OF DEATH
<br />� L'E?'ART'��EI�TT C�' CCI�:�ZERCE �
<br /> BI?RTATJ CF TT"� CE;,TSU� Social Securitz No.- - - - - - State File No. - - - -
<br /> . LA � O. E4 .
<br /> (�) Count� Hall
<br /> (b� City or tot�rn Gr�nd Island
<br /> ( c) N�.�:e of hospital or institution: 1�3b �iJ. 11 Ave.
<br /> ( d) Length of stay: In no�pital or institution- - - -
<br /> In the communit 2 rs.
<br /> . A R�� E�1 E OF �'CEAS :
<br /> (a) St�.te of :�ebr.
<br /> (b •Co�znt Hall
<br /> � Y
<br /> ( c} City or town Gra.nd Island
<br /> ( d) Street Na. 1Q20 W. 12th
<br /> (e) If f:�rei�n born, how lon:� i n U. S.A. - - - -years.
<br /> ___
<br /> _._ ..._._ - �_ ._
<br />', . a FL�LL ��3Ar'E�'�-:er�r;� Otto �eufer _ _ _.
<br /> . (b) If vetera.n n�.me war- - - - - - - - - - - -
<br /> . Se�1 P�ale . o or or r�.ce ' e a �ng e, w�ao*rrea, marr�e , ivorced, married.
<br />' 6. (�) �?�.:ne of husb�.ncl, or wife Eliz� May Seufert ,
<br /> b. ( c) Age of husba.nd or T,�ife if �live- - -yrs.
<br /> 7. E�rt� d.ate cf deceasea Oct. 17, l��ti-
<br />� . A�'sE: YearsT� ^�onths 1 ��.ys �— f�l�ess than one �ay - - - - -hr. - - - - -min.
<br /> 9. Birthpla.ce Tor:��.noxie, Kansas
<br /> 10. Ustzal �ecu�at'i�n Auto A�ech�,nic �
<br /> � 11. In a a�tr,y or busir�ess- - - - - - -
<br /> FATHFR " ��O TH ER
<br /> 12. N�.me A�am Seufert 1�+. M�iden na.Me Caroline Gabriel
<br /> 13. $irth�l�.ce Tr�, � ' 15. Birthplace U. S.
<br /> 16. a Inforrr.�}�t � s own si�^nature Eliza Seufert
<br /> t ) .�
<br /> (b.) Aciress Gra,nd Islanc?, �`�ebr.
<br /> J.7(a) Burial (b) Da.te ther�of Nov. 5, 1Q47 '
<br /> (c) Place; burial or cremation Gr�rid Isla.nd, tiebr.
<br /> l�(a) Signature of funeral director Geddes Funeral Home
<br /> I'' (b) Address Gra��d Island, �1ebr. .
<br /> I� 7.9(�?) Date received local registr�r Nov 2� 1��-7 (b) Re�istrar ' s Signature F. S. White
<br /> T�tF.15f�'I��TCAT ON
<br /> 20. Late of dea.�h: ��onth Nov. day 23, 1�47 10 hour A.M. minute- - - -
<br /> 21. I hArebS� certify tna.t I attended the deceased from- - - , 1�--, to- - -, 19-- that I last
<br /> say h-- a.live on---19-- ancl t'r_a.t �eath occured on the �ate and hour stated above.
<br /> Ir�media te c�.use ef death - Dead "or. arrival, Basa.l skull fracture, Due to Heart Attack( Coronary)
<br /> Due tc- - - -Oth�r conc�itions- - - - - � (Duration
<br /> r2agor f in in�;s : Y AN
<br /> Of operatian- - - - - - - (Underline the cause
<br /> Cf Autopsy- - - - - - - - (to which death should
<br /> (be char ed statisticall
<br /> 2. f dea.t t�rere ue to ex ernal cause , fill in the following;
<br /> (a) Accic�ent, suicide, or homicide (specify� accident
<br /> (b) Date of occurence- - - - - - - - - - - - - - - - - - - - - -
<br /> (c) jr�here did in,j�ry occurGrand Island, Hall, tdebr.
<br /> ( d) . 11id in,jury occur in or about home, on f�.rn, in ir.dustrial place, in public place. Home.
<br /> ?�n�ite at wor�- - - - - ( e) i�ea.ns of in,jury heart attack & fe1.l.
<br /> 23. Si�na,ture Dr. Carl I�Iap��i�re (M. D. ^r �ther) M. D.
<br /> Address Gr��nd Island :de�r. 1��A �ate si�nEC_ 11/25/�+7
<br /> 2t1. I �iereby certify I �ersor.ally emb�lmed the �ody oP the deceased named hereon.
<br /> Emrnett H. Benson
<br /> License No. 1706
<br /> This certifies �the above to be a Tri�e Cony of an original certificate on file ?�_�ith the
<br /> Sta.te Dep�rtment of �?ealth, Bureau of Vital Statistics, �*hich is tY�e legal depository for
<br /> vital recorcls.
<br /> ( COR�'} !�. S. Petty M. D. "
<br /> ( SEAL) Director of Health and Sta.te
<br /> Registrat Lincoln, l�Tebr�.ska.
<br /> Dec li� lg�
<br /> Filed for recard tY�f ?� d�y of January, 19�+� �:t lo ' clock P.P!. �., .��[ �-�-�- ,
<br /> e� s er o f �-ds. '
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