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3�9
<br /> NIISCE�I�AN�OUS RE�CORD V
<br /> 290SQ-TN[AUBO�TINHGO.iR11NDIEL�ND.NFBP. . � �� . �
<br /> l�. CAUSE OF DEATH MEDICAL CERTIFICATZON Interval Between
<br /> Enter only one eause per I. DISEASE OF COPJDITION Onset a d Death
<br /> line for (a} , (b), and (c) DIRECTLY LEADI�TG TO DEATH (a) Endocardit�.s, 7 �,y�
<br /> This does not mean the mode ANTECEDENT CAUSES DUE TO (b)virus pneumoni� �- wks.
<br /> of dying, such as heart Morb�.d conditions, if any,
<br /> �ailure, as�henia, etc. It g�,ving rise to the above
<br /> means the disease, in,�ury, or cause (a) stating the DUE TO (c) . . . . . . . . . . .
<br /> complica�ion which caused underlying cause last.
<br /> death.
<br /> II. OTHER SIGNSFICANT CONDITIONS
<br /> Condi�ions contribu�ing to the death bu� not
<br /> related to the d3.sease or condition caus�.ng death. malaria
<br /> 19a. DATE OF �PERATION
<br /> 19b. MA,JOR FINDTNGS OF OPERATION
<br /> 20. AUTOPSY: Yes No
<br /> 21a. ACCTDENT, SUIC�DE3 HOMICIDE (Specify)
<br /> 21b. PLACE OF INJURY te.g. , in or about home, farm, factory, street, office bldg. , ete. )
<br /> 21c. ( CITY OR TOWN) (GOUNTY) (STATE)
<br /> (If rural area, write RUR.AL)
<br /> 21d. TIM� OF (Month) (Day) (Year) (Hour)
<br /> INJURY m.
<br /> 21e. TNJURY OCCURRED
<br /> Whi1e a� �Tork
<br /> Not S�'hile at o�
<br /> 21f. HOW DID INJURY OCG�7R.�
<br /> 22. T hereby eertify �hat T attended the deceased from 12/l�j, 19�4�, to 1�14, �.9�+g, that
<br /> I last saw deceased alive on 1/l�-, 19�9, and tha'� death occurred at �:30 P.m. , from
<br /> the causes and on the da�e 5tated above.
<br /> 23a. SIGNATURE (Degree or �3.tle)
<br /> C. H. Maggiore M.D.
<br /> 23b. ADDRESS Grand Island, Nebr.
<br /> 2j c. DATE SIGNED 1-17-�+�
<br /> 24a. BURIAL, CREMATION, REMOVAL (Specify)
<br /> t�ur ial
<br /> 2�-b. DATE 1-1�-49 �
<br /> 2�-e. NAME OF CEMETERY OR CREMATt38Y Westlawn Memorial Pk
<br /> 24d. LOCATION (City, town, or eounty) (State)
<br /> Grand Zsland, Nebr.
<br /> 25. FUNERAL DIRECTOR�S SZGNATURE ADDRESS
<br /> L3.vingston-Sondermann Grand Island
<br /> DATE REC�D BY LOCAL REG. JAN lg i9�+9
<br /> REGISTRAR�S SIGNATURE F. S. Whi�e
<br /> THIS CERTIFIES THE ABOVE TO BE A TRUE COPY OF AN ORIGTNAL CERTIFICATE ON FIL� WITH THE
<br /> STATE DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY
<br /> FDR �tITAL RECORDS.
<br /> (CORP) W. S. Pett . M.D.
<br /> (SEAL) DIRECTOR 0 HEA TH AND TA E REaIS
<br /> LINCOLN, NEBRASKA FES �+ 19�+9
<br /> F'�led for recor d �his l� day of May 1949, at 2 :30 o � clock P.M.
<br /> ��w.� G%��-�
<br /> eg s er of ee s �i'
<br /> 0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0-0
<br /> CERTIFICATE OF DEATH
<br /> NEBRASKA DEPARTMENT OF PUBLSC WELFARE Do not write 3.n
<br /> Bureau of Health--Division o� Vital S�atistics this space
<br /> CERTIFTCATE OF DEATH �156
<br /> l. PLACE OF DEATH
<br /> County Hall
<br /> Township ( If dea'�h occurred in a hospital
<br /> City Grand�s an No. Street St. Francis Hospital ( or institution give its NAME
<br /> 2. FULL NAME Marie A ice Manle y ( ins�e a d o f a t r e e t a n d n u m b e r
<br /> Residenee 20�- East 10 St. , Grand Island, Nebr.
<br /> Leng t h o f res idence in city or �own where death occurred yr mo da. How Iong in
<br /> U. S. if of foreign birth yr mo da
<br /> PERSONAL AND STATIST� P�CUL�-
<br /> �. SEX Female
<br /> . COLOR OR RACE White
<br /> 5. �ingle Married W3.dowed Divorced------Married
<br /> 5a Tf ma,rr3.ed, widowed or divorced
<br /> HU3BAND af or WIFE OF F. B. Manley
<br /> 6. DATE OF BIRTH (mo. ) Jan (day) l6 (yr. ) 1�61
<br /> 7. Age Years 67 Months 6 Days 15 Tf less than l day hrs. or m3.n.
<br /> �. OCCUPATION OF DECEASED
<br /> (a) Tracle, profess3.on, or pa.rticular kind of work Housewife
<br /> (b) General nature of indus�ry, business, or establishment in �rhich employed
<br /> (c) Name of employer
<br /> 9. Birthplace ( Ci�y or own MeCombs,
<br /> � and
<br /> ( 8tate or country T11.
<br /> 10. Name of Father ---------Deaxn
<br /> 11. Birthplace vf Father City or town and State or country Kentucky
<br /> 12. Maiden name of mother Ursula Reyburn �
<br /> 13. Birthplace o�' mother City or town and 1�tate or country Greenup County, Ken�ucky.
<br /> 11#�. Informan� F. B. Manley,
<br /> Address 20� East 10 St. , Grand Island, Nebr.
<br /> 15. Filed AUG 27 192� V
<br /> Regi�trar H. E. Cli�ford
<br /> PdEDICAL CERTIFTCATE OF DEATH
<br /> 16. DATE OF DEATH u
<br /> Au st112
<br /> � 9 �
<br /> Mon'Gh Day Year
<br />
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