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��� OUS RECORD V
<br /> IUIISCEI�I�ANE �
<br /> �
<br /> 29058-TN[AUCUlTINECO.GRANDISLIINC,NlBP. �
<br /> 23. If deat�� �ras �.ue to externa.l. causes (violer.ce) fill in also the following:
<br /> Accident, suicide, or homicide: Date of in,jury , i9
<br /> Where d3.d in,jury occur:
<br /> S�ecify whether in,jury occurred in industry, in home, or in public place.
<br /> l.�anner o�' in,jury
<br /> Nature of in�jury
<br /> 24. Was c�ise�.se or in jury in any �r�y rela�ed to occunation of deceased: No
<br /> If so, s�ecify
<br /> (Si�ned) H. C. Tdichols, A�i. D.
<br /> (Address) 4 & Pine Strs
<br /> Grand Is?and �?ebr
<br /> THIS CERTIFIES THF.. ABOVE TO BE A TRUE COPY OF AN ORIGINAL CERTIFICATE ON FILE taITH THE STATE
<br /> DEPARTP•ZE'�?T OF HEALTH, BUREAU OF VITAL 5TATISTICS, ?}JHICH IS �'HE LEGAL DEPOSITORY FOR VITAL
<br /> RECO?�DS.
<br /> ( CORp) - ��1. S. Petty.M. D.
<br /> . (SEAI,) DIRECTOR OF HEALTH AND STATE REG-ISTRAR
<br /> LINCOLN, PIEBRASKA SEP 27 1�1-�
<br /> Filed for record this 5 day of October 1949; at 3:30 o � clock P.M. ���� �����
<br /> Register of Deeds
<br /> 0-0-0-0-0-0-C-0-�-C-O-O-O-O-�)-C)-^-0-0-(:-C�_0-0-7-0-0-Q_0-0-0-0-0-fl-^v-0-0-0-C-0-0-0-0-0-0-0-0
<br /> I STANDARD CERTIFICATE OF DEATH
<br /> NEBRASKA (STATE� DEPARTMEIJT 0�' HEALTH
<br /> Division of Vita1 Stat�stics
<br /> STANDARD Cr^�RTIFICATE OF DEATH
<br /> DEPARTMENT OF COT�1?��CE
<br /> BUREAU OF ^�?� C.Fr�SUS Social Security No. Sta'te File I�1o.
<br /> 1. PLACE OF DEATH:
<br /> ( a) County Ha11
<br /> (b) C3.ty of�own Grand Island
<br /> ( e) Name of hospital or institution: �10 ��est Second
<br /> ( d) Length of stay: In hospital or 3.nstitution
<br /> In this community tzao years
<br /> 2. USUAL RESIDENCE OF DECEASED:
<br /> (a) State Nebr.
<br /> (b) County Ha11.
<br /> ( c� City of �own Grand Island .
<br /> ( d) Street No. 2116 �nlest Di�,�ision
<br /> �e) If forei�n born, how long in U. S.A. •'
<br /> 3 (a) FULL NAME Edt�in CZair Severin
<br /> � (b) If veteran, name war `
<br /> . Sex r�Iale
<br /> 5. Color or race tinite
<br /> 6:; (a) Single; T-J1G�.OL�red, �narried, divorce married
<br /> 6 (b) Name of nusband or ��rife Louise Severin
<br /> b (c) Age of nusbancl or wif e if alive yrs.
<br /> 7. Birth da.te of decea�sed Oct. 1 Z902
<br /> (Month) (Day) (Year)
<br /> �. AGE: Years �5 T�Zonths 21 Days 1 If' less than one day hr. min.
<br /> 9. Birtnplace Rembrandt, Io:,ra.
<br /> 10. Usual occu�ation Salesman.
<br /> 11. Industry or business-Drug supplies & drugs
<br /> (12. Name John Severin,
<br /> Father � 1�. Birthplace _
<br /> Nlother t 1 . P�Iaiden name .
<br /> (15. Birt'rlplace
<br /> 16. (a) Inform�.nt ' s own signature Mrs. �'. C. Severin
<br /> (b) Address Grand Island, Nebr.
<br /> 17. (a) b�_�rial
<br /> (b) Date thereof Jan. F, 1�4�
<br /> ( c) Place : buri�1 or cremat3.on Grand Island.
<br /> l�. (a) Signatur e of funeral director Livin gston-Sondermann,
<br /> (b) Address Gr�.nd Islanc�, �Te'�r.
<br /> 19. (a) JAN 12 1���-� (b) F. S. ti�Thite
<br /> Da.te received local registrar Registr�,r �s signature
<br /> MEDICAL C�RTIFICATION
<br /> 20. Date o� de�.tl:l: '�Zonth Jan. day 2 194� 10 nour 45 minute PM.
<br /> 21. I hereby certify that I attended tne deceased from Nov, 19�-7, to Jan 2, 19��; that I
<br /> last sa�,,� nim a�ive on Dec 20, 1��l-7; and that death occTarred on the date and hour sta.ted
<br /> above. Duration
<br /> Immediate cause o�' death Coronary Thrombosis few �inutes
<br /> Due to Coronary solerosis ,.
<br /> Due to
<br /> - ---_.�_.,___._. _. ._._.
<br /> Other conditi�ns
<br /> ( Include�re�nancy z�sit i�i n 3 months of dea�n�-
<br /> ���a,jor findin�;s :
<br /> PNYSICIAN
<br /> Of ot�erations
<br /> Of autopsy ?Jnderline the cause to which
<br /> death should be charged sta.-
<br /> tistically.
<br /> 22. If death ��as due to external causes, fill in the fo1lo�Ting:
<br /> ka) Accident, suicide, or homicide ( specify)
<br /> (b) Date of occurrence —
<br /> � c) rSThere aic� in jury occur: � ---�---� —`"
<br /> �ity or totiJn ounty ate -
<br /> (d) Did injury occur in or a'�out home, on farm, in industrial place, in public nlace�
<br /> �,r�hile ��.t T,�.rork: (e) T•leans of in�jury
<br /> 23. Signa.ture Udilliam P�I. ?�TcGr�th �M.D. or other) �JiD
<br /> Address Grand Island, Nebr. Date si�ned 3 Jan�
<br />�
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