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<br /> I�II�C�I�L.ANEOUS I�.ECORD V
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<br /> 290SQ�TN[11Y60S71NECO.GB�NDIlLAXD.NEBR. . . � '
<br /> November y�, 19�3 and filed for reeord on November 16, 19�3 and recorded �,n Book 87 at
<br /> Pa�e 16 of the Deed Records of Hal1. County, Nebraska, sub�ec�, how�ver, �o a reservation
<br /> for said grantors to �he usz of said premises for l3.fe; tha,t under date of December 17,
<br /> 191�8 affiant knot�rs of his o�,rn personal kno�rledge that the said Martha Christensen departed
<br /> this life in Grand T�land, Nebraska and the remains were buried in the Grand TsZand °`
<br /> Ceme�ery under date of December 21, 19�8.
<br /> Further aff iant saith not.
<br /> James Livin�s�on_
<br /> Subscribed in r��y presence and sV�Torn �o before me �his 27 �: day of 5eptember, 1.9�9•
<br /> (SEAL) C. T_. FlozfJer
<br /> Natary Public
<br /> My commi5sion ex�aires �he 9th day of September, 1955.
<br /> Filed f or record this 28 day of September 19�9, a� 1Q:00 .s�',clock A.M.
<br /> ������ N
<br /> REGISTER OF DEEDS
<br /> 0-0-0-0-0-G'-�0-•0-�-0-0-0--0-0-0-0-Q-Q-0-0-0--0-0-0-0-Q-Q-d-0-0-0-Q-0-0-0-0-0.-0-0-0-0-0-�-Q-
<br /> C EF�TI FI CATE 0�' DEATH
<br /> r _____.__. ,
<br />' NFBRASKA (STATE) DEPARTMEI�IT 0�^ HEALTH
<br />' DIVISION OF VITAL STATISTICS
<br />` STANDARD CERTIFICATE OF DEATH
<br /> DEPARTI�:?T Or COP�'t�ERCE
<br /> BUREAU OF THE CL�TSUS Social Security. No. None St�,te File No. 107�1
<br /> 1. PLA�E 0� DEATH:
<br /> (a) Coun�y Ha11
<br /> (b) City �r town Gr�_nd IsI�nd, Nebraska
<br /> (c) Na�?e oi hosnital or ins�itution : (If autside city or town 1i mtts, ti�rrite R'JRAL)
<br /> Lutheran Hos��it�.l
<br />' {If m'� in hosni�«.2 or institution, i�Trite street number or location)
<br /> (d) Len�tn o�' sta�: In. hospital or institution 10 days
<br /> I In tnis co nrnunit�T 1 year
<br /> ( Specify ti�znetizer y�s, mos. or c?ays)
<br /> 2. USUAL RESTDEi�10E OF DECEASED: -
<br /> (�) �t�te Nebrask�, (b) County Ho�rard
<br /> (c) City or ��t�m �`r�,nd Tsland (If outside city or. to��m limits, write R'JRAL) �
<br /> �
<br /> (d) Street ido. 11 So. Ki:nball {If rura� iv o i
<br /> � � e 1 cat on) 5_ ,�„
<br /> ( c ) If forei��n born, no?�,r long in U. S. A. � Over �-0 years.
<br /> 3. (a) F?JLL NA ME P�S. MARSE SOELBERG �
<br /> �. (b) If veteran na.r�e �rar None-
<br /> . Sex Female
<br /> ,5. Color or r�.ce White �
<br /> 6. �a) Sin�;le, jaidotiaed, ma.rried, c�3trorced --�-Widot��ed
<br /> 6. (b) Name o�' husband o�^ z�,rife Soren N. Soelb�rg
<br /> 6. ( c) A�e oy I�usban�� o-r t�a ife if al.ive ----- yrs . . .
<br /> 7. Birtr da�e of deceased April � 9 18��-
<br /> (Month) (Day) (Year)
<br /> &. ACE; ��ars P�2onths Days If_less th,.�n_one day -
<br /> 7 5 --h.r. - --min.
<br /> 9. Birthplace I��A Denmark
<br /> (�ty, �o�n or county) St�.te or forei�n country) -
<br /> ��'. Usual occupation ' Housewife
<br /> 11. In�.ustry or business Homemax��n�
<br /> Fa th er -
<br /> l�. Name Ma,r�inus Henriksen -
<br /> 13. Birthpl;� ce NA Denmark
<br /> City;t;own or county � tate or forei�n country}
<br /> Mo�her �
<br /> l�-.��en Name Ana Skow
<br /> 15. Birtti�place NA Denmark
<br /> City, �own or countv (5���,te or foreigr, cot�nt�^y)
<br /> 16. (a) Informants ourn si�nat�.zre Mar�;aretha I�yers
<br /> (b) Address Grand �sland, Nebraska
<br /> 17. (a) Burial (1�) Da�e �nereof 11--22-4&
<br /> ( Hurial , cremation or remova.l) Montn-Day-;�ear
<br /> (c} Place ; burial ar. cremation E1ba Cemetery
<br /> l�. (a) Si�n����ure of funeral director Keating I�brtuary �
<br /> (b) Address St. P��.�1., Nebraska
<br /> 19. (a) 11-25-�-� ' •' - ' ' � (b) Carl Ericksen
<br /> I (Date reco^ded :Loc�.l reJistrar ) (Regi�trar �s Signature)
<br /> M"
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<br /> T
<br /> r.,DICAL CERTIFICt.TIOPv
<br /> 2C�. Date of deatn: I� nth November da,y 16 19�-� 6 hour 40 minute P.M.
<br /> I 21 . I here�y certify that I at�ended the deceased f rom Nov. 5, 19�-� to Nov. 16, 19�-�
<br /> th�.t I ]a t�= r � �
<br /> _ st � h a '
<br /> a�� e_ llve on Nov
<br /> . I�- 1 �r� ana th�.
<br /> 9 t cleat:n o
<br /> , ccurred on �he date ar�d hour
<br /> abo�re
<br /> Im�edza�e c��.?tse of death Coronary Occl.usion Duration Sudden
<br /> Due to Va�.Hysterecto_���_- for z�roca sus �
<br /> Y . n 1 c�a s
<br /> Due t - -----
<br /> � Y
<br /> I o L
<br /> Ot'rler co r�di�ions ( Znclu<ie nregnancy �rithin 3 montns o�' death)
<br /> Z�ia,j or f in�tin;s :
<br /> �f �peration Va�•. hysterecto�y PHI�SICIAN
<br /> for procansus Underline the cause to
<br /> Of Au�onsy None
<br /> which death sho 1
<br /> u d be ha
<br /> c rged ,
<br />; statistically.
<br /> 22. If death T���.s c�ue to external causes, fill in the followin�:
<br /> (a) Acci.dent, su�cide, or homicide (jp�cify) ---
<br />! (b) Dat� of occurrence
<br /> ( c) a�there did in�jury occur ? �City or ta�,Tn) ( County) ( State)
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