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<br /> I�IISCELI��°�N�OU� R�CC�RD V
<br /> 2905E-TH[AUCUfTINEC0.6RANDISLIIMD.NlBR. 1+ � � .
<br /> CERTIFICATE OF DEATH Sta.te of Nebraska Do not write in this
<br /> Bureau of Health-Division of Vital space
<br /> Statistics D �.�!}
<br /> Form 2�-3 CERTIFICATE OF DEATH
<br /> 1. PLACE OF �JEATH
<br /> County Douglas
<br /> Township- - - ( If death occur�ed in a, hospital -or
<br /> City Omaha No. - - - - Street County Hos�ital ( institution give its NAA�E •instead of street
<br /> ( number. . .
<br /> Length; of residence in cit,y or town wh�rP death occured 8 yr. mo- - da.
<br /> How long in U. S. if of foreign birth - -yr. - - mo. - -d�..
<br /> 2. FULL NAI�ZE Charles Martin
<br /> Residence 1716 B. Street
<br /> PER ONAL AND STATISTSCAL PARTICULARS
<br /> . EX Male . 0 R or RA i e 5. Single , M�rried, ?rJid.owed, Divorced- - -Married.
<br /> a. If married, *aidot�red or divorced HUSBAI�ID or WIFE oP Nora May Brown
<br /> �. lJH11,L ur�I'�'I mo June c�ay 1 yr. 1
<br /> �. Age Years _70 Months 7 Days � If less than 1 day Hrs. - - - -or Min.- - - -
<br /> . ra e, profession, or particular kind of work c�one, as �r�inner, sa,wyer, bookkeeper, etc.
<br /> Laborer
<br /> 9. Industry or business in ?�hich T�rork w�,s done, as silk mill, saw mill, bank, etc.
<br /> Soldiers Home
<br /> 10. Da,te deceased last worked �,t this occupation (month ,and year) .Feb. 1932
<br /> 11. Tot�.l time ( ears) sUent in the occu ation 20.
<br /> . Birthnlace ity or town and State or county- - - ndiana �
<br /> 1 .N�me of Father Unkown
<br /> 1 . Birthplace of Fatner ity or town anc� ate or ountry - - -Unknown
<br /> 15. Maiden name of Motner - - - - Unknown
<br /> 16. Birth l�,ce of Mother Cit or town �.nd State or country - - - -Ur�known
<br /> 17. INFORMAI� Mrs. ora Martin Address 171 B. St. Omaha,
<br /> l�. BURIAL, CREI�I'ATIOr�T, OR REMOVAL
<br /> Place Holy Sepulchre Cemetery Date 1/27/33
<br /> 19. U�dDERTAKEI� BreT�rer Korisko�Address Omaha, ebr. �
<br /> � 20. Filed 1-31 1932• Phoeb� 0. Donnell Registr�r.
<br /> T�ZEDICAL CERTIFICATE OF DEA H
<br /> ; �' l. DATE OF DEATH 1-25-Zg33. �
<br /> , ?_2. I HEREBY CF,RTIr^Y, That I attended dece�.sed from 1-11-Zg33, to 1-25-�933 I last saw
<br /> him �.live on 1-25-1933 deatn is said to ha.ve occurr�d on the date stated above at 11 : 55 P.M.
<br /> � The ?�rincipal c�use of death and rel�ted causes of importance in or�er of onset were as follows :
<br /> Fracture of femur
<br />' Contributory c�.tzsea of importance not related to principal cause:
<br /> Chronic �?yocardial de�;ener�tion.
<br /> Name of' operation Anplication of cast.
<br /> UIYi�,t test confirmed di�:�nosis Xray. Was there an autopsy No.
<br /> . f death r,�r�,s due to ��ternal caused violence fill in also t e folloiaing:
<br /> Accident, suicide, or homicide, Accident of in�jurey 12-1�, 1932.
<br /> ��There c�id in,jury occur, Omaha.
<br /> Specify t�het��.er in,�ur�r occurred in industr;�, in home, or in �ublic place.
<br /> M�,nner of in�ury. Struck by Automobile t accident)
<br /> Nature of in,jury, Fractare of femur.
<br /> . � as isease or in.jury in a.ny way rela e to oecup�a.tion of decease . o.
<br /> If so, s�ecify
<br /> ( Si�;ned) Chas. J. Shumek, P�I. D. �
<br /> _ :��d�rP�>s) Doug. County. Hosp.
<br /> Tnis certifies the abov e to be a true copy of a.n oribinal certific�te on file with
<br /> the S'Gate Department of Health, Bureau of Vital Sta.tistics, which is - ��e legal depository
<br /> Yor vital recor ds.
<br /> (SEAL) Z�. S. Petty, M.D.
<br /> Direo�or of Health and State
<br /> Registrar Lincoln, Nebraska.
<br /> Filed Por record the 10 day of March, lg�� at 1 :30 0 'clock P. M. �., �
<br /> Register of Deeds.
<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-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-
<br /> CERTIFICATE OF DEATH
<br /> •
<br /> I. FULL NAME Florence Va,nBuskirk
<br /> 2. PLACE OF DEATH: (A) COUNTY Los Angeles
<br /> (B) CI�� OR TOti�TN L nw�od .
<br /> outside city �r own limits, write rural
<br /> (C) NAME OF HOSPITAL OR INSTITUTION St. Francis Hospital
<br /> Tf not in hospital or institution, give street �umber or location
<br /> (D� LENGTH OF STAY: (S�ecify t�rhether years, mo nths, or days)
<br /> IN N��PITAL OR INSTITUT ON �3 Weeks
<br /> TI� �.'H�� G(7T�Zr�U�32TY 3 �eeks IN CALIFOR�TIA 29, Yrs. �
<br /> (.E) IF FOREIGr1 BC�FtT3, HO�ti� L�NG I�1 T-H� U. S. •;A ? YEARS
<br /> 3. USUAL RESIDENCE OF DECEASED.
<br /> (A) STATE California _ _ -
<br /> (B) COUNTY Los Angeles
<br /> (C) CITY OR TOI�TN Compton
<br /> If outside city or to�:n lirnits write rural.
<br /> (D) STREET N0. 1.212 No. Spring St.
<br /> 3 E) IF VETERAN, NAME OF �^lAR none
<br /> 3. F) SOCIAL SECURITY N0. n�ne
<br /> �. 5EX Female
<br /> 5. COLOR OR RACE - Cauc. ',
<br /> 6. (A) SINGLE, MAR.RIED, WIDOWED OR DIVORCED Widowed � �
<br />�. 6. (H) NAME OF HUSBAND OR WIFE Thomas VanBuskirk
<br /> k;� 6. (C) AGE OF HUSBAND OR Z�tIFE IF ALIVE Years.
<br /> 7 , BIRTHDATE OF DECEASED Feb. 2 , 1
<br /> Month Day ear. �
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