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<br /> 1vIISCELI�ANEOUS �.ECORD V
<br /> 29058-TN611UOU6TINECO.iPANGI3LAND.NCBR. � . - . .
<br /> AI+'FTDAVIT, ETC. �
<br /> �'orm 3�� . STA�'E �F NEBRASKA I3o not wri�e in this spa,ce
<br /> Hureau ot' Health--I3lvisian of Vital StatlstiQe B 1$43
<br /> CERTIFICATE �F DEATH
<br /> l. PLACE OF DEATH �
<br /> Coun�y Hall (If death oecurred in a hospi�al
<br /> T wns
<br /> o a ie or institutlon iv i�s N
<br /> p � g e AME
<br /> City a ro �0 8treet (instead of street and number. .
<br /> Len�h o� residenae in ai�y or town where death oceurred „yr mo 8a.. How long 3.n U.S.
<br /> if ot' fcareign birth yr mo da - ►
<br /> � 2. F'ULL NAME Mar �nM 1�`e`re
<br /> ResideMCe a ro
<br /> PER80�3AL AND STATISTICAL PAI3TICULARB .
<br /> 3. SE3� �'ema.le
<br /> 4. COSAR Qr RACE White
<br /> �j. Si1��le
<br /> Married Widowed
<br /> �idowed
<br /> Divarced
<br /> 5a. If , married, wldowed or divorced
<br /> HUSBAND of
<br /> . �r
<br /> WIFE 0f W�dowed
<br /> 6. DATE mo. y q 5 (Yr. ) 1��j6
<br /> 7. Age �ear$ - Months Days If le�s than 1 day
<br /> - 7� 9 4� Hrs. ar Min
<br /> OCCUPATION
<br /> �. Trade, profession, or partieular kind oY �rork done, as spinner, sawyer, bookkeeper, etc
<br /> 9. Industr9 or business in which work waa done, as silk m311 saw mi1.1, bank, etc
<br /> 14. Date deQeased laat worked.at this oceupatlon (month and year)
<br /> 11. TOtal time (yea,rs) apent in this oacupation
<br /> 12. B�.rthplaae (City or town Canada
<br /> ( and
<br /> (S�ate ar �o�ntry
<br /> l�. Name of Father Ha�den
<br /> l . Birthpla�e� ( �o�o�n ingstort
<br /> of aMd
<br /> Father Sta�e or country Canada
<br /> l5, I�aiden name o�' Mother Brid�e n e�r
<br /> lC. Birthplaoe ( City o�► owr� ipperary
<br /> oP ( and
<br /> Mo�Cher ( Sta�e or c4untr� Irelanc�
<br /> 17. INPbRMANT C�eo Myers
<br /> (Address�—
<br /> 1ffi. B�?RIAL
<br /> Place Cairm Date Febr 21 1 1
<br /> 19. 4� �'ahn a
<br /> (Addreas ro
<br /> 24. Filed_ _ Febr , , e en a
<br /> eg 8 raT'.
<br /> V.M.W.
<br /> t =' : MEDICAt, CERTIF�CATE OF DEATH
<br /> 21. DATE 4F DEATH Febr 19, 1 1
<br /> 22. I HEREBY CEA�TI , . , a " a ende�r deceased from Febr 2, 1931, to Febr 19, 1931 I last
<br /> saw her alive an Febr 19, 1931, death is sald to have vccurred on the date statedabone, at
<br /> �jt�5 A.M. The prineipal cause of death and related causea oP importance in order of onset
<br /> were as follc�w�t ���,�bpa1 A o lex Date oP onse'�
<br /> A
<br /> Contribu�ory causes of importance not rela,ted to p�in��.pal Qauae:
<br /> �ame of operatlon Date oP
<br /> Wha.t �Ceat �or�Yirmed dia�nos a. Was there an autopsy:
<br />, �3. IP death was due to extern cauaea v o ence�) t'i11 in also �he followln�:
<br /> �
<br /> Aecident, su3.cide, or homicide.__r____Date of in�urq , 19
<br /> S�here did in�ury ocetu�:
<br /> ; . �. _ ``� pec y eity or own, aoun Y, and a e
<br /> Sp�cify whe'�her in�ury oecured in industry, in home, or 3n publie pl�c3e
<br /> MB,ruaer of in�ury
<br /> N�.ture oY 1n,�ury
<br /> 2�F. Was di�ea�e or n . y n any wa3� related� ,to oacupa�ian oY deQeased: �10
<br /> If so, specify -
<br /> (Sigr�ed M.R.�rs�-- , M.D.
<br /> (Address o e � .
<br /> TFiIB CERTIFIE3 '1'�iE ABOVE T� BE A TRUE COPY �F AN ORIGINAL CERTIFICATE ON FILE WITH THE STATE
<br /> �EPARTMENT �F HEALTH. AUREAt)' OF VITAL STATiSTICB, S�PfIICH IS THE LE(�AL DEPOSITDRY FOR VITAL
<br /> REC4RD8. �
<br /> (C�RP) W. S. Pett .M.D.
<br /> (BEAL) D 4 0 D E 8
<br /> LINCOLN, NEBRA3KA JUL i6 19�9
<br /> aE1vERAL AFF'rDAVIT--Long
<br /> I�1 RE: NOATH ONE HAL�' OF NORTHEAST QUARTER (I��NE'� ) OF SECTI�N TWENTY �2�) T�WNSHIP ELEVEN (11)
<br /> A10RTH RANaE ELEVEN (11) WEST �F THE SIXTH P.M. F3ALL C�UNTY, NEBRASKA
<br /> STATE �F 1Vebraska )
<br /> es. I�ouis Myers of the town of Cairo, CO�nty of Hall, and State
<br /> Ha11 Co�ntq, � o#' Nebraeka, being duly sworn, doth depose and say �hat he
<br /> is. ot' legal a�e. is the son of Mary A. Myers. now deeeased
<br /> �,nd SS the bro�her of Emma S. Vierk. The said l�ary A. I�.yers made her home with the afPiant
<br /> !'rom the time of�he death of her husband until she he�aelP died. The �vo ahecsks o� Emma *
<br /> c
<br /> Vierk, xhieh are .attached her�to, are eigned by Mary A. M3�ers and represent a year$ payffien
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