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<br /> PUBLIC HEALTH SERVICE DErsTARATETrdy,NTOF NEBRASKA
<br /> FEDERAL
<br /> - Bureau of Vital Statistic.
<br /> ! 1 BIRTH NO 126__.. CERTIFICATE OF DEATH STATE FILE NO
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<br /> 41 "..T ' 11 *This dors net mean tle ANTECEDENT CAUSES
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<br /> 0:1'6.;i: : II.(nIIER SIGNIFICANT CONDITIDNS
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<br /> 11...DAIE OP OPERA (26.MAJOR 1-LIDING8 OF OPERATION 120.AUTOPSY?
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<br /> ..t, ....'& 2... 21d.TIME (Month) (Day( (Yea+) (lioor)1 2,6,,,,Ir.n..t,T.LCURI(nET7 217 11(7W DID INJURY OCCUR?
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<br /> au i 21e. GN T ' --- (Dorm.or utle) 22, ADDRESS 1 210.DATE SIGNED
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<br /> 2.,,IIIIIIIA C R E hi A '241).DATE I 141:,A A.r c1,1-l EMETERY DR CRLIA,A90-EY12.11d.(L)OCAT ON)INt0,,Beern,or woos') r,(Stedo)
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<br /> .. .. DAT/E RFAN7 tIrILOCAL I tor 7R7•XS SIGNATEIJE zy, AL 731 ..L.TOR•B SIGNATURE ADDRESS
<br /> JUL _V_1951sa.1 ..7`,--.4',.---(7) I --,r-,7'.,
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<br /> renit !RIES. l'ff A 60VE TO BE A TRUE COPY OF AN ORIGINAL
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<br /> CE FICATt.ON lt.4_NkITH THE STATE DEPARTMENT OF HEALTH,
<br /> jpIR U OF WIT/IL 41A1FISTICS, WHICH IS THE LEGAL DEPOSITORY
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<br /> 4,r. ...ek T. DIRECTOR VITAL ST IST AND ASSISTANT STATE REGISTRAR
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