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<br /> I�IISC�LLAN�OUS R�CORD V
<br /> 29088�TNlIIUOtlfTINECO.iRAND15U1ND.N[BR. � � � . . � . .
<br /> 6. COL�R or RAC� White
<br /> 7. MARRIED, NEVER NiARRIED, WIDOWED,
<br /> I3IVOR�ED Widowed
<br /> 8. DATE OF BTRTH . 1-8-18b4
<br /> 9. Age (In yrs.. last birthday 8�:
<br /> l0a USUAL OCCUPAT�ON Houaewife
<br /> lOb. KSND �F' BUSINESS OR .INDUuTRY Home
<br /> 11. HIRTHPLACE Mo�tpelier V't.
<br /> 12. CIT�EN OF WHAT COUNTRY: U. S.
<br /> 13. FATHERiS NAME Willlam Goodwin
<br /> 14a. M�THER.t 5 1+�ATDEN NA�lE El�zabeth F'ay
<br /> 14b. NANlE OF HUSBAND DR WTF"E .
<br /> 15 . WAS DECEASED EVER IN U. 3. ARMEI� F"ORCES: l�a.
<br /> ' 16. SOCIAL SECURITY Aio.
<br /> 17. INFORMANT' S NAME or Signature & Address Mrs. Chas. Kaufman-C€rand Island
<br /> l8. CAUSE OF �EATH
<br /> MEDICAL CERTYFICATION
<br /> �. DISEASE OR COPIDITION DTRECTLY LEADING TO DEATH (a) Bronchial Phenemonia Tnterval
<br /> , Between
<br /> ANTECEDENT CAU5E� DUE TO (b) Influenze Onset and
<br /> Death
<br /> DUE TO (c ) Z weeks
<br /> 3 weeks
<br /> II. OTHER SIGNSFI�ANT CONDITIONS Frac�ured hips 4 Mo.
<br /> 19a. DATE OF OPERATION
<br /> 19b. MAJOR FINDINGS �F OPERATTOAt
<br /> 20. AUT OPSY? Yes No.
<br /> 21a. ACCTDEIJT SUTCIDE HOMTC�DE
<br /> 21b. PLACE OF INJURY
<br /> 21c. (CITY OR TOWN) (COUNTY) (STATE)
<br /> 21d. TIN1E OF I1�JtJRY
<br /> 21�. IIJJURY OCCURED
<br /> 21f HOW DID INJURY OCCURY
<br /> 22. I �����3�" �.�'�'��.��• `�Ua'�: I attended the decea.sed from Oc�t. 1q4�9, to Marah 6, 1950,
<br /> tYLat I last saw the deeeased alive on Marah 6, 1950, and tha.t death occured at
<br /> " 11 P.M. , from �he caus�s and on the date sta'�ed above.
<br /> 23a. 5I(�NA�U�E �. H. Hombach
<br /> 2�b. ADDREBS Grand Island, Nebr.
<br /> 2�a. DATE SZGATED 3-9-50
<br /> 24a. BURIAL, CREMAT�ON, RET�OYAL Burial
<br /> 2�b. DATE 3-9-5�
<br /> 2�e. NANiE OF CEMETERY �R CREMATORY " Grand Ialand Cemetery
<br /> 2�d. LOCATION Grand Island, Nebr�.ska �
<br /> DATE AE� iD B� LOCAL REG. MAR. 13 1950
<br /> REGISTRAR' S 3IGNATURE F. S. White ADDRESS
<br /> 25. FUI�ERA.L DIREC�OR�B �TGNATURE Livings'Gon-3ondermann Grand Island, Nebragka
<br /> 2F. I hereby cert�.Py T personal.ly embalmed the body of the deceased
<br /> "James D. Livin�ston
<br /> Lieense No. 1833
<br /> THIS CERTIFIES THE ABOVE TO BE A TRUE COPY OF AN �RTGSNAL CER�IFTCATE ON FILE WITH THE
<br /> 5TATE DEPARTMEATT OF HEALTH, BtJAEAU OF VITAL STATISTIC5, WHTCH IS THE LEGAL �EPOSITORY-
<br /> FOR VITAL RE�ORDS.
<br /> (SEAL) Frank D. Ryder _ M.. D.
<br /> DIRECTOR OF HEALTH AND
<br /> STATE REGTSTRAR, L�NCOLN,
<br /> . � NEHRASKA Mar 20 195�
<br /> F�.l�d for reeord this 24 day of Nlarch 1950, at 11:45 o�eloek A.M.
<br /> , � �� �� �"
<br /> REGI3TER OF DEEDB
<br /> o=o-o-o-o-o-a-o-o-o-o-a-a-o-a-o-o-o-o-o=o-a o-b-o-o-o-o-o-o-o-o-o-o-a a--a-o-o-o-o-o-o-o-
<br /> AFFTDAVIT
<br /> AFFIDAVIT. � ;��
<br /> STATE �F NEBRASKA ) ` <�
<br /> : SS Jphn �. McCarthy, being Pirs� duly eworn upon oath, deposes
<br /> HAL� CQUNTY ) and says that he is personally acquainted with Ma�thew Faes, �',`:�
<br /> who wae named as, and duly appointed, executor of the Last
<br /> Will and Teetament oP Katie Fasa; �ha.t he was pre�ent at the �i�ning of that eertain
<br /> exeQUtor� g deed dated November ,�, 1g45, covering "�;t ;',
<br /> :�,�;
<br /> : ,
<br /> �o�� 3,�,7 and 8 in Block �6 of CharleB Wasmerte Third Addition to the City �
<br /> of Grarx�. Island, Hall Count�r, Nebraska, �: �
<br /> . �,� ;. �
<br /> which said deed wag �3�ned by �his afflant a�d Matt F'ase, and conveyed aueh property to �;;�
<br /> G. La,t�arenee Gorman and Ann K, (�orman, as �oin� tenants and not as tenants in �ommon, �
<br /> which sa,id deed is r�corded in Book 89 of Deeds at Pa�e 228 in the real estate reQOrd.s '
<br /> of H�,7.1 Coun�y, Nebraska; that the said Matt Fass, who signed such deed aa exeeutor o�
<br /> the Estate of Katie Fass, Deeeased, and Matthew Fass, who was named and appoi��ed as � '
<br /> executor of the Es�ate of Katie F'ass, are one and the same person.
<br /> a.
<br />
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