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<br /> It PIS i9]IVS)REV.4 4) - �$'rATE OF NEBRASKA •
<br /> 1 El.ERAI.,I:c cnrrY AGENCY
<br /> 1 II OLD) E\ r sElv :E DEPARTMENT OF HEALTH H J %—J V 3 J Bureau of Vital Stalintlen
<br /> w lirli No 126 CERTIFICATE OF DEATH STATE FILE NO
<br /> LAI F OF DEAT11 --'-- ) ce
<br /> n Y LSI'AL SIUt NyE(When Aena•d IiY If IM1 tituaao:raWanw
<br /> )l'STY / ?/ - SCA1'E / ' b COUNTY fora dmLeloo).
<br /> �,b .ICY IIf k1 SOy7rite R U 1 E 1 C H OF c.CITY(If u mrtwr•'II 4„if he_))uII�IALL
<br /> II �+t o/(. S'AY''1 4d z}O{,I.t ) 1•4 i/ I
<br /> I 1 1 I 1.1.NAM}.D1 If hurinal A u IU V" r.t or—.- A ■r12ltEC (i ora,_Five Ipcatlm)
<br /> 1 111.
<br /> • ucK,un, ADDRESS
<br /> i E! 1.NAM}:OF tl (M■Jdle) C.( 1 4.DATE (61'9'')1) (IA,) (Y4ar)
<br /> 1 'EASED J))) �/,/J t'
<br /> or Print) /�f -t V l./S /1/�.iA/fL/• .1 I./ DEATII./AYU4'25/,/3
<br /> e 5 EC I(R or ketCEL].MARRIED.NE ER MARRIED 11 DA E OF RIIt1'n 9.Aire(In Fra.II C"odor_II Yr.If I.A,r 26 Hre.
<br /> F11� `` Wll O)V}v1 DIVORCED(Speeitly�r/.r .}o n latt bir bdarl Moe !/DJa_r• hour M,v
<br /> n,•,_--,
<br /> I \I, ) ILI 111 N IGt�k,nA� k u 1N' Iit SI\/'e//y{h Itc�R'1�/4Clty,Itpwrl aunty)ISZte lli.I:IT1.Etd OF WHAT
<br /> 1 f n f 4'.71 L,4 o f n Ind) INDUSTRY PLAC or fore) COUNTH D
<br /> < rr^• r
<br /> m / r-z r-•--�'•rte � `�' I -.2/ �-,s,.e,6 �tnrr�' t ILL
<br /> Y I�\TIIEIt N 191E 16 AOO IIER'S MAIDEN ME 149.NAME OF IIVSDA-D UR WIFE '
<br /> n
<br /> '. - "'2CIJ' .ti-„,,S.A I ,' s . /.. ',r 44/4 I 1- .....i�. ! •AB A
<br /> 1 I WAS } E\SEI EVER IN U.S ARMED FIO RUES? 16.St A.y/SECURITY IT INFORMANT'S N E or Sien,tuce& rese
<br /> mP . (Yen.nu,or unknovoOilif r..s,,2,e war or dates,,”Aro a) NO.I , ' 2 d• );„6,/,..49
<br /> .S F Al }\Tlr - -
<br /> 1/1EDICA ()EICTEL""CATION •Interval Retwmn
<br /> E• Enter war o 'r 1 I ISE\SF.OR CONDITION _ On and Death
<br /> B I I 1 ) L) J 1) 1 IItEGTLY LEADING'tU DEA'Cit• •
<br /> O I N I]La
<br /> St TbI,dors 00 mean the \NTECEDENT CAUSES N
<br /> rondo of lure, suth Y DUE TO (b) 1;
<br /> y heart failure, a.thenla. Morbid rendition.,If any,fl,lnj --
<br /> elc. It mean. the die- rice to the abate came(a)static• C,`D//
<br /> p" asst,Inlur),ar ron'plira- the underD-'ref{tease last. DI)E TO I \ .` ��l1L
<br /> w "ion nhich caused death - -- - -+- -t -"""
<br /> _ ' IL.1U:it SIGNIFICANT CONDITIONS \� 1.
<br /> �{ Conditions rentrl6vliee to the death but not `�; F. V
<br /> x3 _ related m me disae or rendition.amine drat .
<br /> I9a.DAE OF OPERA-I Pb. AJOR FINDINGS OF OPERATION 20.AUTOF$1?
<br /> Fe T Yea❑ No TIONI I /
<br /> )
<br /> .la.:\l't'IDE', . ISpecl(2) 216.FL:\CE OF INJURY(U.e.,In or about'21e.1CITY OR TOWN) (I:OUNTY) (STATE)
<br /> Esun ICE: I1,.m(,tarn',factor,.�.treet,offico bide.,etc.) (1f rural men,write RURAL)
<br /> 21d.'1111£ (Month) (Du,) (Year) (Hour) 21e..INJURY CCURRED 2If.110W DID INJURY OCCUR?
<br /> OF W Fria ar WorOk
<br /> °o INJURY m. Not File at Work 0 (,�
<br /> E 22.t hereby cc d M.t 1 attended the deceased 1r... /� ` to- I9S�7..�that I last saw de-
<br /> 9ed atit- ...b)9 ...Cared that death oa` a ..a.‘54.m.,from the apse and on I/O daft s ate.)abate.
<br /> D ADlll[ES5 N-)
<br /> • 1 111)1,3 L. y11 M A t..26h 1 Ty, i 24c.N. f.OF CEMt. 1:7•-•,.•' A RY `'LOCATION c T (Sate)
<br /> L. f10\ I<FJ]IU\\L lSpvelll](- p�/ p rf /� -/ sf�., /
<br /> UAIE RECD[3Y LOG•". REL'IS"H�)YS6+GNAC.'nE 25.FUN INL L[RECEOtt'S SIGNTTURt: ADUR.. .:
<br /> II ----.—��� 7"�� I �t dr ...e T7/. ?.. ..r . vr6v
<br /> \ •4): staff . I' ,•'PHIS W •' � d4:S. '-.O BE A TRUE COPY OF AN ORIGINAL
<br /> CERT*.,= FfL� + `,• —E STATE DEPARTMENT OF HEALTH,
<br /> BUR• .I '+•; ,TAL`ST: 1.'• 4i,WHICH IS THE LEGAL DEPOSITORY
<br /> FOR 1 ' . • ;
<br /> + ;' ' + P''- ITAL S ATI•TICS AND ASSISTANT STATE REGISTRAR•
<br /> '.7,',NEBRASKA tossed N 'vember 30, 1953
<br /> + (2te.
<br /> ,, .., 4 i, Al6Le„,,,j - f/,(31e..i/ad-oe.
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<br /> .'4r
<br /> s Ar or I='' � tie.,s
<br /> ! hereby>aertfty that th.%instrument W
<br /> ont.er.d on Numerics) :rzlecC and $:ied €tK'
<br /> ",®cord
<br /> ilsy of -ab' . at/; a3 0
<br /> y dOlb reoordod So book
<br /> Afar..�...,.e. otri €4. e.e . at w:tr-.
<br /> &
<br /> Register ot
<br /> Depeity
<br /> r
<br /> iftWili S°4- C.1 1
<br /> _ / 13
<br />
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