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PHS-798(VS)REV.4-48 STATE OF NEBRASKA 0i, ,
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<br /> FEDERAL SECURITY AGENCY DEPARTMENT OF HEALTH
<br /> Copy
<br /> ' PUBLIC HEALTH SERVICE Bureau of Vital Statistics n . Geodes. • �
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<br /> gBIRTH NO. 126. ._.. CERTIFICATE OF DEATH STATE FILE NO.
<br /> 1. PLACE OF DEATH - 2. USUAL RESIDENCE (Where deceased lived. If institution: residence
<br /> . N a. COUNTY Lancaster a. STATE Nebr b. COUNTY Hallbetore admission).
<br /> a
<br /> U c.b. CITY (If outside corporate limits,write Rural) c. L E N G T H OF CITY (It outside corporate limits, write RURAL)
<br /> To° Lincoln ISTAY TOWN Grand Island.
<br /> d. FULL NAME OF (If not in hospital or institution. give street d, STRRET (If rural, give location)
<br /> gl o HOSPITAL OR
<br /> Z NST TUTION Veterans Ho@@tal address) ADDRESS 1709 N. Huston St.
<br /> I 3. NAME OF a. (First) b. (Middle) o. (Last)
<br /> i2 O DECEASED 4. DATE (Month) (Day) (Year)
<br /> b a (Type .r Print) Raymond G Stimpert DEATH Sept. 27. 1947
<br /> 0 1. SEX 6. COLOR or RACE 7. MARRIED. NEVER MARRIED 8. DATE OF BIRTH 9.Age(In yrs.If Under 1 Yr.If Under 24 Hrs.
<br /> m WIDOWED, DIVORCED (Specify) last birthday) Mos. Days Hours Min.
<br /> a V l Male White I Married �eb.16.191f� 31 17 111
<br /> a 10a. USUAL OCCUPATION (Give kind of work 10b. KIND OF BUSINESS 11. BIRTH- (City, town or county) (State 12. CITIZEN OF WHAT
<br /> done during most of working life,even if retired) OR INDUSTRY PLACE or foreign co t y) I' CtO,gUATRY?
<br /> .d g 1 Iceman IIce Hastings. iebr u
<br /> 13. FATHER'S NAME 14a.MOTHER'S MAIDEN NAME 14b.NAME OF HUSBAND OR WIFE
<br /> e I Walter R Sttbmpert Martha Knosp I Geraldine Stimpert
<br /> .>.: q$ i 15. WAS DECEASED EVER N U. S. ARMED FORCES? 16. SOCIAL SECURITY 17. INFORMANT'S NAME or Signature&Address
<br /> I w CC9d ` (Yes, no, or aaknown)(If yes, give war or dates of service) NO. Geraldine Stimpert. Gran Isl
<br /> c5 l' .zb ! Yes � World War 11. I
<br /> and,
<br /> -FIN,. 1 18. CAUSE OF DEATH MEDICAL CERTIFICATION Nebr Interval Between
<br /> K. 2 ' Enter only one cause per I. DISEASE OR CONDITION
<br /> n - m •Onset and Death
<br /> ▪a a line for (a), (b), and (c)
<br /> ro q DIRECTLY LEADING TO DEATH* t1S•arc1ia1 $. �1('
<br /> of ill ng1
<br /> wilt; di does t me the ANTECEDENT CAUSES a=.7'e moe*This no h DUE TO (b/.('�rV 1ac h yp.rt.Xopk
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<br /> � nap,, heart failure, asthenia. Morbid conditions, if any, giving
<br /> j 0zo etc. It means the_dm- rise to the above cause(a) stating
<br /> o°v ease, injury, or complica- the underlying cause last. DUE TO (c)
<br /> U o lion which caused death.
<br /> M oe A 1 II. OTHER SIGNIFICANT CONDITIONS
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<br /> N] 1 Conditions contributing to the death but not
<br /> ypQ related to the disease or condition causing death.
<br /> '0A 19a. DATE OF OPERA- 19b. MAJOR FINDNGS OF OPERATION 20.AUTOPSY?
<br /> •��E. TION
<br /> a I Yes D No D
<br /> y. W,• a• 21a. ACCIDENT (Specify) 21b.PLACE OF INJURY (e.g., in or about 21c. (CITY OR TOWN) (COUNTY) (STATE)
<br /> F7 a a SUICIDE home, farm, factory. street, office bldg., etc.) (If rural area, write RURAL)
<br /> i .f. HOMICIDE
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<br /> 9 q 21d. TIME (Month) (Day) (Year) (Hour) 21e. INJURY OCCURRED 21f. HOW DID INJURY OCCUR?
<br /> '2 OF
<br /> INJURY I While at Work
<br /> P $ m. Not While at Work 0
<br /> c; $ 22.1 hereby certify that I attended the deceased from ,19 ,to ,19 ,that I last saw the de-
<br /> Pa A ceased alive on ,19 ,and that death occurred at m.,from the causes and on the date stated above.
<br /> a g '1 23a. SIGNATURE M. D. (Degree or title) 23b.ADDRESS 23c.DATE SIGNED
<br /> J. S. Walsh. LincolnNebr. Lincolnd Nf&br 15t pt27/54
<br /> w 24a. Burial 246. DATE 24c.NAME OF CEMETERY OR CREMATORY 24d. LOCATION(City,town,or county) (State)
<br /> F '° CREMATLON ept, 29/p.947 Grand Island Hemeter
<br /> (Specify y Grand Island, Nebr.
<br /> CC tz DATE RECD BY LOCAL I REGISTRAR'S SIGNATURE At FU10L 13 OR'S SIGNAT 3W DDRESS .
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