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<br /> I�IISC�LI�AN�OUS I�ECORD V r
<br /> 28058-TNl11U6tltTINECO.aRANDISLAMD.NlBR. , � � '�
<br /> CERTIFICATE OF DEATH
<br /> PHS-79� (Vs} REV. 4-4� 5TATE' OF NEBRASKA
<br /> FEDERAL SECURITY AGENCY DEPARTMENT OF HEALTH
<br /> PUBLIC HEATH SERVICE Bureau of Vital S�atistics
<br /> BIRTH No. 126 . CERTIF�CATE OF DEATH STATE FILE N0.
<br /> 1. PLACE OF DEATH
<br /> a. COUNTY Hall " �
<br /> b. CIfiY (?F T4WN (I#" outs3ae carporate l�.mit5,. krri�e Ru��,�. : Wood River; Idel��. '. _
<br /> C� LEN�'�H fJF S�AY (in this• p�ace) life�
<br /> d. FULL NAME OF HOSPITAL OR TNSTTTUTION (Tf not in hospital or institutian, give s�reet
<br /> address or location) none �
<br /> 2. USUAL RESIDENCE ('r�There deeeased lived. I� ins�itutions residence before admission) .
<br /> a. STATE Dtebr. b. COUNTY Hall
<br /> c. CTTY OR T4wN fTf outside corporate I�.mits, write RURAL) Woo-d River
<br /> d. STREET ADDRESS (If rural, give loca'�ion)
<br /> 3. NAME OF DECEASED a. (First) b. (Middle) c. (La.st) �
<br /> Carl Edward Brittin
<br /> �-. DATE OF DEATH (Month} (�ay) (Year)
<br /> 7 7 19�+9
<br />� 6. SEX male
<br /> . COLOR or RACE White
<br /> 7. MARRIED, NEVER I�IARAIED, WTDOTn�ED, DIVORCED (Specify) married � �
<br /> �. DATE OF BIRTH 12-17-1910
<br /> 9. Age (Tn yrg. last birthday� 3� IP Under Mos. 6 If Under 1 Yr. 6 Mos. 20 Days
<br /> If Under 24 Hrs. Hours Min.
<br /> 10a. USUAL OCCUPATION (Give kind of work done during most of working 1ife, even if retired)
<br /> Oil tank Wagon Salesman
<br /> lOb. KIND OF BUSI�TESS OR INDUSTRY
<br /> 11. BZRTHPLACE (Ci�Gy, town or county) (State or foreign coun'�ry) Wood River, Nebr.
<br /> . 12. CITI7EN OF WHAT COUNTRY: U. S. A.
<br /> 13. FATH�'S NAME Edward Brittin �
<br /> li�-a. MOTHER�S MAIDEN NAME Mayme Boyle
<br /> 14b. NAME OF HUSBAND OR WIFE Alfi ce Brittin
<br /> 15. WAS DECEASED EVER TN U.S. ARMED FORCEB: (yes, no, or unknown) no (T� yes, give war
<br /> or date of service) no
<br /> 1.6. SOCIAL SECURSTY N0. 506-09-69�6
<br /> 17. ZNFORI�SANT�8 NAME or S3.gnature & Address N. T. Brittin Wood River Nebr.
<br /> l�. C�USE OF DEATH En�er only one cause per line for (a) , (b) , �.nd (ej
<br /> Th3s does not mean the mode of° dying, such as hear fa3lure, asthenia, etc. It means
<br /> the disease, in,jury, or complica�ion which eaused death.
<br /> MEDICAL CERTIFTCATION
<br /> I. DTSEASE OR CO1V'DITION i�IRECTLY LEADING TO DEATH {a) Carcinoma transverse Colon
<br /> Tnterval Between Onset and Death 6 mo.
<br /> ANTECEDEIVT CAUSES DUE TO (b�
<br /> Morbid conditiona, if any, giving rise to tne above cause (a} s�ating the underlying
<br /> cause las�G. DUE TO (c)
<br /> TI. OTHER SIGNIFICANT CONDITIONS
<br /> Condit�.ons contributing to �he death but not related to the disease or condition causing
<br /> death.
<br /> 19a. DATE OF OPERATI ON
<br /> Z9b. MAJOR FINDINGS OF OPERATION
<br /> 20. AUTOPSY: Yes No
<br /> 21a. ACCIDENT SUIC�DE -I�OMICIDE (5pecify)
<br /> 21b. PLACE OF INJURY (e.g. , in or about home, farm, Pac'Gory, street, office bldg. , ete, )
<br /> 21c. ( CITY OR TOWN) (COUNTY) (STATE)
<br /> (If rural area, ��rite RIJRAL)
<br /> 23d. TIME OF INJURY (Month) (Day} (Year) �HOUR) m. �
<br /> 21e. INJURY �CCURRED While at j�'ork No t irlhile at Work �
<br /> 21f. HOW DID TNJURY OCCUR:
<br /> 22. I hereby eertify that I attended the d�ceased Prom 6/25, 19�-9, a�G 7/7, �9�9, that I
<br /> last saw deceased alive �n 7/7, ig49, and tha'� death occurred at �:23 p.m., �'rom the causes
<br /> and on the date stated above. (Degree or title)
<br /> 23a. SIGNATURE F. Ervin King M.D.
<br /> �3b. ADDRESS Wood River, Nebr.
<br /> 2jc. DATE SIGNED 7/9��+9
<br /> 24a. BURIAL, CR�MATION, REMOVAL (Speci�y) Burial
<br /> 2�b. DATE 7/10/49 -
<br /> . 2�+c. A?AME OF CEMETERY OR CRErQATORY Wood River Ceme'�ery
<br /> 2�-d. LOCATION (City, town, or county) (State)
<br /> Wood River Nebr
<br /> DATE REC�D BY LOCAL REG. JUL 13 19�9
<br /> REGISTRAR�S SIGNATURE F. S. k�hite
<br /> 25. FUNERAL DTRECTOR�S SIGNATtTRE R. E. Apfel
<br /> ADDRESS Wood River
<br /> N. B. This is a permanent record. Every item of information should be carefully subplied.
<br /> AGE should be stated EXACTLY. Exact statement o�' occupa'�ion is important. Give cause a�
<br /> death in plain terms.
<br /> TO BE ACCOMPLTSHED WHEN BODY IS EMBALMED
<br /> 25. I hereby certify I personally embalmed the body of '�he deceased named hereon.
<br /> Raymond E. Apfel License No. 15�9
<br /> THIS CERTTFIES THE ABOVE TO BE A TRUE COPY OF AN ORIGINAL CERTIFICATE ON FILE WITH THE STATE
<br /> DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY FOR VITAL
<br /> RECORDS. �CORP)
<br /> SEAL) W. S. Pett . M.D.
<br /> LINCOLN, NEBRASKA AUG 31A191}9E STRAR
<br /> Filed for record thi� 1� day of September 19�-9, at �:15 0 'elock P.M. �
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