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<br /> Ill '"c e. s)REV.I Iw STATE OF NEBRASKA ,.>f
<br /> Plan}.H ti,sad t R TY Acr.NCY DEPARTMENT OF HEALTH 7
<br /> _I I'I'I')It II}:.t1.T1i SERVICE
<br /> Bureau 9,l%7W Statistic* '.5'�
<br /> LrD..I 126 -.. CERTIFIl'ATE OF DEATH STET! FILE NO
<br /> `fie+ .AeR OF U MATH --- i CSI'AL RESIDENCE-Wp dew.ed had If t”thatloo:..dd.nee Y,
<br /> col STY f� I I /DATE a(,or_ G ff1Ut'YI
<br /> Wore td�lrlaal.
<br /> I.CITY(If 59,7.14.eoryof 1 Santa ite floral) _ !E h C T H OF a CIr?(If oytW.Uaryorn I,m/y�.,wrie.o AURAL)" TiiWN-LS YYi IlI�1�.4..2C IsrAY� TOWN cYM Ytci ,s A lid. -- y
<br /> ,1 11.1.1 N ME D} ,fl , n ,.r ,r: ,.,r ,.7 J.STREET Of I..Iw )
<br /> 41 ONf•IT 1 O IIIAAAAAA - ""RP! ,/ O1. ;.•,
<br /> zI vrlTt.-1,l mx � •1,G{yl�py � _ 2 V 2 � !'Q /.Gf/�// — V.(,'�I
<br /> E YAMP.OF IPu.4 M1441 1 );(Lela) I.DUAFTE (Booth) ID.,) (Ye.) ;@
<br /> a I E EASED 1}t �) �n ( I J l A
<br /> ▪ ITS..or FI.OAr�l1�r —iF DM1sL4 c,.Il_ dYT DEATH /Ploy 2L )/e51
<br /> SEX r 6 COLOR or RACE MAIIRIF',NEVER, ■AHRIID I.'ATE OP BIRTII I.A..(In yn.,lf Dade l Yr.H Uoder II H.a. �5,,�
<br /> C ! /5//c. I vhI'/- I WIDOWED.'IVOIICEIt I Spa.)!,) , -C ,I (tut . )I M. I D . Hour. Mln. .f` i•
<br /> I ',1 CP15I I' .l !ottilt lob KI 1 } III SIN(55 I).BIRTH- (City.ton or memo) Bt.t.l IS.CITIZEN OF WHAT
<br /> J of.or:r i f :.■I 11 N INDUSTRY 1' CE Of foret.a�wa y) COUNT Yt
<br /> m I Dilr3�t?p /o; (far. a,4.?, 1,a 4C_Laan/O& ? ,o1J, I (I "./9. �3k
<br /> W I 1 FATHER S NAME ..MIITIIER'S AI EN NTME LI,E..�?45E OF HUSBAND OR WIFE lj,r,..
<br /> ''. I yipfr�a4c. I1.G.4i54 J/ /E.5 04. /%r3'lfAC/ ea es,-- )Y
<br /> i! E !II EVER 1 U S AIRMEE.FORCES'1 I. 1.NL SE(:UNr 7.INFO' AN-'B N or Sign., •A 14;
<br /> Ss I 1 or L .1 If ash-of mrelw I O. /�� / 4
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<br /> llyoe e.... So 6 a- S..es_i • �_. a :
<br /> ,z�"V I . tl'E } 1 EA'1'IR 41EDICAL CERTIFICATION ?Mre l.MV. •lif
<br /> ,r,. raw."rot 1 IIISEtSE OR t'ON'1TIOr I O•�•
<br /> 35 Irr,.for(.1.rb1,saJ lc); k. 3,
<br /> 1,0^ DINECTLY LEADING TO DEVTII• 3�
<br /> m L . 'This dam net mesa...1 ANTECEDENT CAUSES { c
<br /> ,ja •, made of dying, mirk as DUE TO(b) ... - ---_
<br /> • pert !.mare, )h. ala, morbid I.be above a 1f (a;Shia.
<br /> ere. I( seem tad dir t W to a1,.Mn saw(U euW.
<br /> G`7iI cam Wary,.r ce“ma. the andr"4"raaa Wt. 'CE TO iel I .1- }()1
<br /> 71on which e..md“ma. f _
<br /> 'S.) II.((THEN SIGNIFICANT CONDITIONS ONS
<br /> 1g3 (.ndld to.cnnlimate or ee tk.death ca ele..t -3
<br /> m -. Li' -r j related to ne dl.....or 7«744 .In.d«9,. -
<br /> ,,, 10a.DATE OF OP I ID.MAJOR FINDINGS OF OPTION ll..AUTOPSY?
<br /> 1 $ it o No
<br /> S e.,..ACCIDENT (Specify) 1 itb.PLACE OF INJURY le. la or.boat Ile.(CITY OR TOWN) (COUNTY) (STATE)
<br /> E I CICI'E
<br /> SUICIDE hone.farm.tartar,.street.office hid..,Mu) (If rural area.Rite RURAL)
<br /> Ill.'1,145 (Rooth) (D.,) (Year) (HO4`)I flee[NJL'RY OCCURRID III.HOW DID INJURY OCCUR?
<br /> I 7 OP WElle.t Work
<br /> 1 - INJURY Not While at Work 0
<br /> ! X 11.1 hereby certify that I attended the deccaeed from ..3-a,.x,7E_e5..1,to .S.dl....,JE.f.J.,that I last.ate the de-
<br /> -
<br /> as1.1 alb,1,m S-a L,195.9,and that death occurred at t../Ii.14m.,from tie cal..*and as the dais stated above.
<br /> 905.rSIGNATURE t (Deane or WM) I1►. •DIES/ Net D TE NONED
<br /> . I f ) i 1. � �_� / SV�
<br /> x,rr y,- tab.DATE I 9,r.N i, Via) t )
<br /> I CREM l Y _1 I w / I • 1�,t�,� /.. /
<br /> j ^ REMOV I -I r�•1 I/•'�) I`�" / ,71'1_sYa4 .I�, - L�/
<br /> I t R f L REil. ••4r - lb. TT Z T ADD?-.t.
<br /> ?14,14 yy
<br /> K F`IES TIC QVEf'TO BF: A Thl1I'. COIN O1 AN ORIGINAL
<br /> CF:WVI • CA E9 :.1 F.Ite VIIITII,THIi STA"I'I': UEIIAI:TIVIENT OF HEALTH H 4
<br /> ItUI21tjAK Op V�{ AI Tf �. �. WHICH 1S ?III: LEGAL F:(;A1, 1)F;{'Otil"('Ohl'
<br /> FOR filinttf a I; ..•,N., i `.
<br /> I ,,
<br /> 44511 r L
<br /> .Arr10 OF ■ITAi ,TA't STliS AN:, Au. ,-.:',' ... - �N
<br /> ( INCnt N, NFRR.SF A, Issued June 19, 1953
<br /> Xis-, . 7V i
<br /> i Vi emit tAk✓ V I , -
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<br /> DEPT. OF HEALTH, STATE OF :,rE SRA.SKA i.
<br /> •
<br /> ARTHUR DOUOLAD CORE, ?R.
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<br /> F et)rk7'y 54 :15
<br /> z 12.115C--_
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<br /> h��liGvJ2t, IO '
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<br /> _713
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