|
I T.SEX
<br /> 4.COLOR rc RACE/1.WAOWED,NDEVO' +. j I Hrz
<br /> m ; Sit I (Sp.oiT) ,— — - rI bl t•.)I Mo.
<br /> I Do III,.
<br /> 106.USUAL OCCUPATION(City kind of work r06.KIND OF UUSN SS 11.BIRTH-(CIt1.
<br /> town o =mar) (St.0.1S.CITIZEN OF WHAT
<br /> I dons ppurure� t of worklan ate,even If nand) OR INDUSTRY PLACE or fordry oonntrT) I COUle1T',RY 1
<br /> S Si _jInK111A11 I e 10.1e I Tle13 -L %cb^aaka J.,, A
<br /> ' wry FATHER'S NAME I It.. -OTHER'S MAIDEN NAME I IN.NAME OF HUSBAND OR WIPE •
<br /> a, 0.innn 6hro riF. F^nn)•**,�I x-#*******
<br /> I IS.WAS DECEASED EVER IN U.S.ARMED FORCES? It.SOCIAL SECURITY Il.INFORMANTS NAME or fll.sntwe&Address
<br /> I (Y.., .,or unknown)(11 lea.Flue wv dates of rr.I.) O.
<br /> Yes I.l 5U5—J7—).'-3 °rs, C.b.Sha:.e,G r .ua Is1,1.1
<br /> f`'•: `AU E At A C'• IF CA I to t 1 w.0
<br /> a: Enler only one oo.e (`/''�`'//�Y��'`.'���',,�,/�, e O
<br /> °3 ; oad. .IZnngt�o'W I ANTECEDOENT CAUSES CONDITION
<br /> IS c etc It or: tM d{1r MecbM c.ndltren.,II eaT.diving
<br /> _ea.e,In).n,.r ea'.Be.- To uNe019.1 5 5uw lul.".dreg DUE TO 1,) _
<br /> ,U. 11 tree wMrh e.nw Lau. ..... _...__.
<br /> ljy 11.OTHER SIGNIFICANT CONDITIONS
<br /> `m9 .-'e' I. Condition.contributivea to the death bet sot
<br /> 3 related to the dime or rendition amain death.
<br /> I9a.DATE OF OPERA- 19b.MAJOR FINDINGS OF OPERATION SC.AUTOPSY?F1 T1ONI Yes 0 No dr
<br /> II..ACCIDENT (BPeoHT) IIb.PLACE OF INJURY(e...,Inn.boot Ile.(CITY OR TOWN) (COUNTY) (STATE)
<br /> iq SUICIDE (home,turn.fvtoop.etraet.f:r, bldg.,etc.) (it rural area,+rfte RURAL)
<br /> b HOMICIDE
<br /> Sld.TIME (Month) (Do,) (Year) (Hosr)I Sl..INJURY OCCURRED 210.110W DID INJURY OCCUR?
<br /> OF While at Work 0
<br /> , S INJURY Not While at Work/0
<br /> . S $ II./heretry/certify that I attended the deccaaed from 3 - (,. ,19.TF,1. 3-//,19 r✓,that I last saw the de-
<br /> �e on.... .'./.0..,194_x,a,id that death orcarred at.. ''.n1.,from the t-aast 9 and on the dat.-.sfn f,vl nb,��-
<br /> ceased alie (n� )/ -�/��(�
<br /> t t no.SIGNAT�/'7'r1�J G/� or OW) I sae. RFS9/Gl 6...c4f"/t.!/I I uDAT73 GNED/.
<br /> 6 Sta BURIAL, C REM A-I Ttb '•:TB I Ito.NAME OF CEMETER OR CREMATORY 11d.LOCATION(qt.town,or count)) (Bt.0..))
<br /> 8 E TIO REMOVA (BFWbi a ^U
<br /> 8 9ErE.,1; Y 3 sa � s'. i a
<br /> .. DATE RECD BY LJCAL II R}[iltfl SAE 3 P-GNy�1RE � �Sd.FUNERAL DIRECTOR'S SIGNATURE r^c ADDRESS
<br /> ill—MAR---1-4-�: I— — --i. w .::)t:sto.^.—Sou. er-c:.. -- ....,...and
<br /> Nebraska e
<br /> ,. I) I w
<br /> THIS tERTI .S Tfic A t ONE 10..BE A TRUE COPY OF AN ORIGINAL
<br /> CERTt A AidtiL ' rTH jeHE STATE DEPARTMENT OF HEALTH,
<br /> BURE4 4 VI'ML A.TLI tCS, WHICH IS THE LEGAL DEPOSITORY
<br /> FOR Vf�,dC1b R: ./ . ra�.'Z/
<br /> ,l�°' ;∎'WWRFC- OR OF ITAL S ATI.TICS AND ASSISTANT STATE REGISTRAR
<br /> LINCOLN, NEBRASKA Issued December 3, 1953
<br /> .
<br /> CERTIFICATE OF DEATH
<br /> DEPT. OF HEALTH, STATE OF NEBRASKA
<br /> CECIL BYRON SHADE
<br /> I hereby certify that this Instrwr±ent was
<br /> entereC en N4ir erical index and `died for
<br /> r*s ore UlL;__ Li'
<br /> •
<br /> ;,d. t December la 53 at 9:00
<br /> o'cie r A. _Li_ d rasa d in book
<br /> No 1 of Mi sea al ra-
<br /> !it of� J
<br /> Reg s'_M,of Dtvds
<br /> Deputy
<br /> t 2.2
<br />
|