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<br /> I�IISCELLANEOUS RECORD W
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<br /> 98289-THEAU6UOTINECO.GRANDISLAND.NEBR. . � .. � �
<br /> SUB�CRIBED in my presenee and sworn to before me this 1'�" day of April, 19,52.
<br /> (SEAL) He rman F'. Buekow
<br /> o�ary Public
<br /> My Commission expires the 17�' day of April, 1956.
<br /> �'iled for reeox^d thi� 17 day of April 1952, at 11:�5 0� eZoek A.M.
<br /> �aGH-a• ��
<br /> Register of Deed$
<br /> o-o-o-Q-Q-o-o-o-Q-e-Q-o-o-o-c�-e�-o-o-o-o-o-o-o-a-o-o-o-a-o-o-o-o-o-v-o-a-o-o-o-o-o-o-e-o-o ,
<br /> CF.RTIFICATF. Or DF�TH � STATr OF I�'F.BRASKA
<br /> DEPAR'�MF.NT OF PL'BLIC WELFARE
<br /> BiJREAU OF HEALTH ,
<br /> DIVISION OF VITAL STATISTICS
<br /> .l, PI.ACE QF DFATH
<br /> County tial]. State Nebr . Registered ho. 2815
<br /> Township or Vil..lage
<br /> City Burkett, I�ebr. No St
<br /> 2. FL?LL I�`�1'�F; Isa.ac Smith
<br /> (a) Residence. A'o Burkett. �'ebr E�ard
<br /> (If non-resident give city or town
<br /> . and state)
<br /> Length of resider;ce in city of town where death occurred: vrs. mos. ds.
<br /> How lon� in t?. S., if of foreigh birth: yrs. mos ' Ds. �
<br /> PERSOT'AL ArD STATISTICAL PARTICULt�RS MF;DICAL CFRTIFICATE OF BEATH
<br /> 3. SFX Male 4. Color or Race White 16, DATF CF DF.ATH (month, day and year)
<br /> S. S ingle, '�tarried, Wid owed, or nivorced March 16th, 1922
<br /> Married 17. I HEREIiY CERTIFY, That I attended deceased
<br /> Sa. If riarried, Wi�o�,�ed, or Divorced fro�. Oct 1" 1 1 t March 16'� 1922 and that
<br /> HL'Sii:Al�� of (or WIFF. of �t-h�currn�c�n e"�a�' '��S' at7e�''above at
<br /> 6. DATE OF FiIRTH April 12. 1840 7:30 P. M.
<br /> ?. AC�F. Year�s 81. Mor,ths 11 Daps 4 � �
<br /> If le s s th a n 1 day-----hrs. or ----min. The CAUSE OF DEATH'f was as f oll ows:
<br /> 8. QCCiJP.1T70r OF PFGEr1SFD Heart Failure
<br /> (a} Trade, pro�'essi.on or pa.rttcular k�.nd
<br /> of worlc Farmer (duration)__yrs mons)_ days�
<br /> (b) Genera.l nature of industry, husiness, or
<br /> establishment in which employed (or employer) CONTRIBOTORX
<br /> (c) 1�'ame ef gTp�10yP.?' (secondary)
<br /> 9. �iIRTHPL�CF City er town duration yrs mons days�
<br /> State er catxntry Penn. 18. Where Was Disease Contracted if not at Place '
<br /> 10, NAMF. OF FATHFR Daniel Smith Death?
<br /> 11. BIRTN.PLAGF OF FATHF.R Pern, Did an Operation Precede Death? No Da�e of
<br /> 12. MAIDF.\ NANIF OF '�SOTNi:R_ Kati.e Stout Was there an Autopsy? No
<br /> 13. B IRTHPI,ACi; OF MOTHI�:R Penn What te st c onf irmed. d iagnos is Y ;
<br /> 14. Informar.t signed) J. V. �i�rsChman M. D. ,
<br /> (Address) 19. Place of Burial, Cremation, or Removal
<br /> 15, Filed APR - 5 7_922 H, E, Clifford Burkett
<br /> Registra.r Date of Burial 3 19/1922
<br /> 20, tTndertaker Geddes '.: W Address Gr Is]_and
<br /> THIS CERTIFIES THE ABOVE TO BE A TRUE COPY OF A'1� ORIGINAL CERTIFICATE ON FILE WITH THE STATF DEPARTMENT
<br /> OF HF,t1T;TH, 6L'REA11 OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br /> C. L. Chism
<br /> (SF.AL) Director of Vita1 Statistics and Assistant
<br /> State Registrar Lincaln, Nebraska
<br /> Issued April 16, 1952
<br /> Filed for record this 1? da of A ril 1952 at 1:30 o�clock P. M.
<br /> Y P �
<br /> ;�a.��.l..r� �%��a�.
<br /> Register of Deeds
<br /> o-o�o-o-o-e-oaQ-ao-o-e-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-e-o-e-o-o-o-o-o-o-o-o-o-o-o-o-o-o-e-o-o-o-o-o-ao-o-o
<br /> AFFIDAVIT �
<br /> J�'._?
<br /> STRTE OF NFI3RASKA )
<br /> )ss, JAMES LNINGSTON being first duly sworn upon his oath deposes and says that he is a
<br /> HALL COUNTY ) resident of Grand Island, Hall County, Nebraska and is a licensed funeral director:
<br /> and mortician and has practiced his profession in Grand Island, Ivebraska for more than Fifteen Years last
<br /> past; that he was well and persona.11y acquainted with Lettie M. Foster, one of the grantees in a certain War,ranty
<br /> Deed convey�.z�g Lot Six (6) in Block Nine (9) in Wiebe�s Addition 'to the City of Gra.nd Island, Nebraska,
<br /> which deed is recorded in Book 83 at Page 360 of the Deed Records of Hall County, Nebraska; that affiant
<br /> personally know� of his own personal knowledge that the above referred to Lettie M. Foster departed this
<br /> life on the Sept. 26, 1946 at North Platte, Nebraska. That Maloney-Gox-E� Kuhns Funeral Home at North
<br /> Platte, hTebraska prepared her remains for burial and Livingston-Sonderman officiated at her funeral which
<br /> was had on the 30th day of Septefi�er, 1946, and that her remains were buried in the Grand Island Cemetery
<br /> in Grand Island, Nebraska.
<br /> Further Aff iant Saith Not. '
<br /> James Livingston
<br /> Subscribed in ny presence and sworn to before me this 1? day of APRIL A. D. 1952. �
<br /> MY COMMISSION EXPIRES Oct 5� 1954, (SEAL) Andrew W. Oliver
<br /> NOTARY PUBLIC
<br /> Filed for record this 17 da of A ril 1952 at 3:00 otclock P. M. � o
<br /> Y P ��iv�,.v C���,�/
<br /> Register of Deeds
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