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<br /> I�IISC�LLANEOUS RECORD W
<br /> .. 99289-THEIIUGUSTINECO.GRANDISLAND,HEBR.
<br /> STANDARD CERTIFICATE OF DEATH ,,�'
<br /> STATE QF NEW MEXTCC3-DEPARTMENT OF PUBLIC HEALTH
<br /> DEPARTMENT OF COMMERCE STANDARD CERTIFICATE OF DEA2H File No. ----------
<br /> Bureau of trie Census Registrar� s No. ______________
<br /> 1. PLACE C7F DEATH
<br /> (a) County Bernalillo
<br /> (b) City or town Albuquer que
<br /> (c) Name of hodpital or inst�tv�'C�on Presby�erian Hosp.
<br /> (d} Length of stay: ln hospital or institutlon Years 0, Months 0, Days 7 _
<br /> (c) Len�th of stay: In th3.s eounty Years �, Months 0, Days �
<br /> 2. USUAL RESIDENCE OF DECEASED:
<br /> (a) ►3tate Colorado (b) County E1 Paso
<br /> (�� City or town Colorado sprin�s
<br /> (d) Street No. 29og W. Kiowa
<br /> (e) Zf f'oreign born, how long in U.S.A.
<br /> �. (a) Will Harry 9�ern
<br /> �. (b) If veteran name War. Spa ni�h American
<br /> . Sex Male 5. Color or race White 6. (a) SinQle, widowed, maxried, divorced Married
<br /> 6. (b) Name of husband or wife Minnie Stern �j. ( c) A�;e of husband or wife if alive�years
<br /> 7. Birth date of deceased March 12, 1�75.
<br /> �. AGE; Years 62 Months 10 Days Yi da�s .
<br /> 9. Birthplace Colle�eville, Penn.
<br /> 1�. Usual Occupa�ion Stone M�son
<br /> 11. Inc�ustry or business Buildin� �C General Stor.e
<br /> Fath�r
<br /> 12. �ame Henry Stern
<br /> 13. Birthplace Unknnwn
<br /> Mo ther
<br /> 1�. M�.iden Name Lillie A. Williamson
<br /> 15. Birthplace Unknown
<br /> 16. (a) Informants own si.�;nature Jim Farris
<br /> (b) Albuquerque, N. M.
<br /> 17� (a) Burial, cremation or removal Removal (b) Date thereof Jan. 22, 41.
<br /> (c) Place; burial or cremation . atte, Nebr.
<br /> 1�. (a) Signature of funeral direetor Richard �. T}�o"rne'.- ,
<br /> ('� Addre�s-S;�rong-Tho�ne, Albuquerque, N. M. -
<br /> (c� Licensed embalmer 0. W. Str�n�
<br /> 19. (a) Date received local re�istrar 1-22-41 Registrar 's signature B. Hurley L.Vl.
<br /> (c) Was Burial or Removal Permit issued Removal Apr. �5 . 4i
<br /> MEDICAL CERTIFICATE
<br /> 20. Da.te of Death Month Jan. day 20 year 1941 hour 0 minute 30 A.M.
<br /> 21. I here�y certify that I attended the deceased from 1�7.3 19�-1 to 1�20, 19�-1, that I
<br /> Iast �aw him alive on 1�20, 1941; and that death is said to have occurred on the
<br /> da�e and hour stated above. due Duration
<br /> Immediate eause of death Perforated �astrie ulcer/to generalitied peritonitis 14 yrs.
<br /> Other conditions
<br /> Ma�or findings :
<br /> f operations: perforated gas�r�c uleer. ,
<br />; Of autopsy
<br /> Where 8as disease contrac�ed Unknown
<br /> was there an inquest X
<br /> 22. IP death was due to external causes fil.l in the followin� ,
<br /> (a) Accident, suicide, or homicide (specify
<br /> (b) Date of occurence ,
<br /> (c) �ihere did in,�ury occur
<br /> (d) Did in,jury occur in or about home, on farm, in indust'rial place, in public place
<br /> (e) Means o� in,�ury
<br /> 22. Signature J. Harry Backmann M.D.
<br /> Address Albuquer que Date si�ned 1I20�41
<br /> State of New M�xico ) ss
<br /> County of 5anta Fe ) I hereby certify the within anc� foregoing to be a true and correc'�
<br /> copy of an ori�inal certificate filed wi�h the state Department of Public Hea1�h of the
<br /> State of New Mexico� ti�itness my hand and the seal af said Department this 14th day of
<br /> August, 1952. �
<br /> By: Audrey Immels (sEAL) Bill Tober
<br /> As�t. �ate e�istrar & Statistician tate egistrar , anta e, ew exico.
<br /> Filed fvr record this 23 day of Au�ust, 1952, at 9:3� o ' clock A.M.
<br /> �d.,.r,..�,
<br /> i ��e�� of eeds
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<br /> ^,FF7D.��'I^' �
<br /> T{` td�i�',f TT `�1�7 !;t�tiCrR�':
<br /> Glenn Ti. Ceddes, �e�ng firsr, du�y sworn or. oatli, deposes an,-� says t:h.at he is a resider.t of th.e Cit3�
<br />� ef Gz��,t�� I�;1:�zr:,�., �t_zi ���:�;�. �ount��, '�ebx�aslca ; �!�at 1?� i_s � l�4ei�s�d f��nibalm�r a.r:d fuiiei-al dit�ector in the City
<br /> of �rar�� T:,l��i3 ar�u tl�at hr h�.�s bc,er: �r.g�be�u ii, ri,�. ;,usir.e��7s <�s a mortic�aii it. tlte ^ity ef Ga•�nd Is?_an:�,
<br /> � �:d�bra5ka, s:tice '1.,: ��.;�:�r• �,` l�Iv; *l�at: l�e e,�as well acquaf_iit;ed �aith T31T'i�].� Swain whe resided ir. t}�e City
<br /> i?r �iI'?,Ilc� �5�.�'St:j� '�tiJt'r�S���� f'lr:� W?�O `y{'i.5 I31I7SC�. 8S �I'�ili�E'E` ]Il t3, �E'I'�:11.t; CIPE'� C�F CC�T'_VE?y'�t!Ct °�T'Otll �;'ill.iam ,ri�J1111�
<br />, �T'FiT"tt C)I`� �`�1 �,i2:` .'c.i:� CSt:*:�(' C�i;SCC_II?E`:j �15 F"'I"1i�;i_1�1:1�. L:�7T 1'i'tt"l'.f' (3� 321 �'t'Al'ti�C?Y1c11. ��.QC� Sevente.cn �l i� lil
<br />� I.t�mL�.�:��t'�, ;�,'� i_t,i��r�, ����,� rrac:C.ior��a1 I_�Cs �ThreP (3) t�n3 Fct,r (�11 in Fract�ioiTal �l,ock Ten (1(�) �f Fvans�
<br />�I �,-l:�:t 3:;ti, L�t:� �F �;��;' T.�����ti:��,� i�c�iil� ad�it:or.s te the. ^i.t�� of ('�rand Island, l�'e'�raska, as surve�d, Platted
<br /> ar_d r���,o,-:�e� ; Fr•�iti..�:�1] T..�� F���: (�1) in Frac�i.�t�al R1.ock "e��ei�teeri (l;� of Lambert�� :Addi�ion ard Fractiona.l
<br /> ?et F;.ee� (�il iz� Ft-ac�i_;;.��I Rloc-ts �'er (1�1 of ?'vatis :13ii�i��i�, :�tth of sa.id ad��itioiis u�in� addi*_.ienc to tl�e
<br /> �'itti� af �',r�raai:� Ts't+��,�, ^'.;-�,1��s1:<�� �� sut���e3�,'�, Fla�ted �c�.� �r�..car•;ic:3, �tilhich sai3 �.�ed was dated September 1.�,
<br /> ��!?:, fi1.{�? F:°� ; .�:,;�=, i_c: �t�e �?f�'ic:t= cf t;he R�gis:,t�r of Dec:?s iri Hall Co�.�nt�-, N�braska, on tl�e 17th d�3° of
<br />, `;����:c�m`t�er�, 3��5, �r���i t.hi.�,?i i;as tL:e�c~d��d 3ii t��c� :~ec��rds of de�d�� an t?oc�ic ;0, at Page 5;�2; rhat he kncnas of
<br /> . . . . . . .
<br /> ?,�s ���a: �;,���,�ec?t-� ��?�.�ti� P�r,�?:a�� ��a��a�, �aa, the ���.fe� af t�'.��� iam Sc�a..����; tlaa* rt�.n sai�i itird.ie Swain died on tl��e
<br /> :�tf.i �.�ss�� �� �'.3;`,~I�-4-! ,xt: t°��. '�ity �f �'r,<i;a 7s1ar7��, `;ebra�ka, ar3�� that at t1�e .*.i.mc� of i�er dea.r.h she was
<br /> : es i }.iti�, Y.�it�; a,�.� :,iaE� �i;� i�f tlia^ said ';'.ill..iam Swain, tl�;�t this affiar:* nrepar•ed the remains of t}ie
<br /> s�i��3 i?�r���i� �T�-�i�: fti�; Luf ;.^�. ; *}��t t}�is af;'iaiit i.�as pe�•�c�i�all�� pre�er�t <<*llen the funer°al services w�r� held
<br />�II f�r tt�-� .:<t;.a �zr���i� c�, -ii�: a,�;.i tha� ���is ��.�'fi.r�r.t ki�ot,-5 c�f h:i� v?ti'I3 know3ed�e, �at. fnl.l�,�ir.g saa.d funeral
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