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cl� � IvIISCELLANEOUS RECORD W �I� 98289-THEAU6USTiNECO.GRIINDI3LAND.HEBR. �� CERTIFICATE OF DEATH �.��1r%y �S'- 9 -f> Dr. G. H. Maggiore '� NEBRASKA (STATE) DEPARTMENT OF HF.ALTH Division of Vital Statistics STANDARD CERTIFICATE OF DEATH ' DEPARTMENT OF COMI�RCE BUREAU OF THE CENSUS Social Securitq No. State File No. R 2663 1. PLACE OF DEATH; (a) County Hall �__��_ (b) City or town Grand Island If o�xtside city or tawn limits, write RURAL) (c) Name of hospital or instit�ition: Lutheran Hospital . (If not in hospital or institution, wxite street number or location) (d) Lsngth of stay; In hospital or institution In this community 3 weeks (Specify whether yrs., mos., or days 2. OSUAL RESIDENCE OF DECEASED; (a) State Nebr (b)County Hall (c) City or town Doni han Rural If outside city or tawn l.imits, write RURAL (d) Street No 41 SF. Doni han :If rural give location (e) If foreign born, haw long in U.S.A. years. 3. (a) FULL NAME Henry Olthoff 3. (b) 'If veteran, name war 4. Sex Male 5. Color or race white 6. (a) Single, widowed, married, divorced Married 6. (b) Name of husband or wife Bertha Olthoff 6. (c) Age of husband or wife i.f al�ve - yrs. 7. Birth date of deceased Mar. 1 187? (Month (Dap (Year 8. AGE; Years 68 Months Daps 5 If les�, than one day hrs. min. 9. Birthplace Doni han Nebr. (City, tawn, or county (State or foreign country) 1.0. Usual occupation 11. Industry or business Farmer 12. Name Anton Olthoff 13. Birthplace Cerman ) Father City, town, or county (State or foreign� country) 14, Maiden name ,1ohanna Olthoff 15. Birthplace Germa.n ) Mother (Citp, *.oum, or county* (State or foreign country 16. (a) Informantts own signature Bertha Olthoff (b) Address Doniphan Neb. 17. (a) Burial (Burial, cremation, or removal (b) Date thereof Mar. 9 1945 Month Day ,Year . (c) Place; burial or cremation Doniphan, Neb 18. (a) Signature of funeral director Geddes Funeral Home (b) Address Grand Island Neb 19. �(�) MAR 12 1945 b F. S. Whitc - (nate received local registrar) Register�s signature MEDICAL CFRTIFICATION 2�. Date of death: Month Mar day 6 1945 7 hour am. . minute � + M. 21. I hereby certify that I attended the deceased from 2 11 45. , 29 , to 3 6 45 , 19 ; that I last sa�r him alive or. 3;6 45 _, 19 ; an3 that death occured on the date and hour stated above. Duration Immediate cause of death Cardiac Failure - Due to Coronary Occlusion 3 wks Due to Other conditions Include pregnancy within 4 months of death) Major findings: Of operations Of .Autopsy PHYSICI:IA 22. If death was due to external causes, fi].l .in the following: (a) Accident, su�cide, or homicide (speci.fy) IInderline the cause ta which death (b) Date of occursnce should be charged statistically. (c) t�'here did in jury occur: (City or town (County State (d) Did injury occur in or about home, on farm, in ind�xstrial place, in p�ablic Flace? Specify type of place While at work? (e) Mea.ns of injur3• 23. Signature Carl. H. Maggiore (M.D.or other) M. D. _ Address Grand 751and Date s��ned 3 6 4.5 I herehy certify I personally ernbalmed the ba�iy of the deceased named hereon. _T. Wal.ter Geddes License T'o. 1738 TNIS CERTIFIF.S THE ABOVE TO BF, A TRt?T�, COPY OF AN (1RIGI?�AL CFRTIFTC�ITE OI� FILE WTTH TFi� STATF DEPART- ME?�'T .�F HF.ALTH, I3(JRF.AiT �F VTTAI� STATISTIGS, ��'HICH IS THF LT:GAL DFPQSITORX FOR VITAL RF;CORDS. (SE.'-1L) C. L. Chism T17RF.CTOR OF VITAL STATISTICS AND �1SS7ST�NT �TATF REGIST2AR LINCOLN, �'FBRASKA *inY 1.7 1951 Filed for record r.his 23 day a.f '�ay 1951, at 11:30 o�cl.ock A, M. (��Z�.� �l�c}-f'�_/ � � " Register of Deeds ; _-- . � ,