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<br /> PAS-99I(V9)REV.4-48 ,0•�o "
<br /> FEDERAL SECURITY AGENCY STATE OF NEBRASKA •
<br /> PUBLIC HEALTH SERVICE DEPARTMENT'OF HEALTH 12477
<br /> Bureau of Wel StatDike
<br /> BIRTH NO. 126...—. CERTIFICATE OF DEATH STATE FILE NO.
<br /> PLACE OF DEA •• — I.USUAL RESIDENCE(Wb.re deceased lived. if lw ,Don:residence
<br /> a.COUNTY '.°- a STATE -- J h.COUNTY ore admission). 1 '
<br /> N' b.CITY(It Ou er mrpora4 Jpy,wri-te Rural).S.T ALY EfN g k H l wOF) c.CITY(I earporet•limlty..er RURAL)
<br /> "TOWN I
<br /> d.FULL NA.E OF hospital or in 'tutlyn glee street address d.STRRET _ (If rural.give IoaHo•.
<br /> HOSPITAL OR '' ` 'or location) ADDRESS • /(
<br /> N INSIITUTIO-j, .,✓ • -A .9-w i., (/ -.:/,
<br /> 'LIAISED O' i—.. Pint) b. Eddie) a(1,1A)' {.DAT.
<br /> DECEASED I .(Dfonth) (Da)) (Year)
<br /> (Type ar Print OF
<br /> ) •�,�r �/ i./�/L_.-II DEATH `�
<br /> SEX 6.COLOR or RAC'7.MARRIED,NEVER MaqRRI•a S.DATE OF BIRTH 9.Aga(In yra If Under 1 r.If Under 24 Hrs.
<br /> a
<br /> WIDOWED.DIVORCEM(S•, y)ry -7 - I Wt b( .day)I Mn.. I D ye I Hours 1010.Ar
<br /> {
<br /> lo a.USUAL OCCUPATIO (Give kind o work lop KIND OF USIER'S IL t1RTH--(C y,town or county)(. to 1 CITIZEN OF WHAT
<br /> e done d1y)hn of working life,even it retired) OR INDU'•1 PLAC or foreign country) CO CO -MYt .
<br /> L FAT E 'S NAME 14..MOTHER'S MAIDEN.fell. lab.NAME OF.HUSBAND OR WI S
<br /> m a l .f&._�...it• •
<br /> O g 1Y.WAS DECEASED EVER IN U.S.ARMED Fee•CES1 D.SOCIAL SECURITY 17.INFORMANT'S M.or• •tare Ss "
<br /> g, (Yee,no,or unknown/HI yes,give war or dates of service)I NO.I , M eu•, ,
<br /> .y G S/f%LJ '�
<br /> sa 4 II.CAUSE OF DEATH MEDICAL CERTIFICATION IoOrval Between ,
<br /> Enter Ir 'au"'per I.DISEASE OR CONDITION t and DeatY
<br /> ST line for(e),16L sued(<) _
<br /> gal� DIRECTLY LEADING TO DEATH* 04-028142.....0 )lti'___ 1, !J. l_.
<br /> (a) , ^M(/JI'XLLd-._(J sass._.__. r"R°rl•
<br /> E 'Thus deer on,mean W ANTECEDENT CAUSES QA"..e-a.v.e wf.L •a-aA/L. ,
<br /> .°- nude of dying, such as DUE TO(b) D
<br /> hest failure, w ._ _ -�: �._/.
<br /> ay asthula, Morb,c.ndlli.n.,If any,glying 1-r�"r.`^ '-�"
<br /> �a , etc. It meavr tae dlr aloe to floe steers raose(a)s411ng
<br /> ease,in)ary,or rd dr.Oh lb..nderlylog ran..WI. UUE TO (e)
<br /> t°UO Hon which uu.d dull sass... .._......_....
<br /> iO�w II.OTHER SIGNIFICANT CONDITIONS /�� . _ "
<br /> i�m� i i -- rtlZadt�e.tbe dirlselnor to idon rausingndeatb. -- t' C Ce 1 K+ LT�wsUT)
<br /> 19a.DATE OF OPERA-I lob.MAJOR FINDINGS OF OPERATION 20,AUTOPSY? 1
<br /> >F TION
<br /> V Yee b( No 0 •
<br /> II..ACCIDENT (Specify) 516.PLACE OF INJURY(e.g.,in or about Ile.(CITY OR TOWN) (COUNTY) (STATE)
<br /> 9
<br /> L SUICIDE
<br /> HOMICIDE rne,bo (arm,factory,street,office bldg.,etc.) (1f rural area,write RURAL)a
<br /> 15 yy 21d.'fIME (Month) (Day) (Year) (Rona) Ila.INJURY OCCURRED Ilf.HOW DID INJURY OCCUR?
<br /> B 7 INJURY mI While ht a at
<br /> g - @`JURY Not While at Work
<br /> g 5 D.1 hereby certify that I attended the deceased from 7-1° ,19.r:. to (ti'Ja',19 r•,that 1 last saw the de-
<br /> 17. eased Wive 0r..-)' ;-?.:9.•F✓ and that death occurred at... Td
<br /> Q...A._nt.,from the caries and on the date stated above.
<br /> K g I3 SIGN -7 (Degree or title) lOb. REM lIt.DATE SIGNED
<br /> �.� IWJ �sla�.d Nov I Iv-i�r
<br /> lei w
<br /> ✓
<br /> a R N I Y. \'(d A I .NAME OTy Y OR C MATORY Had ON(City,Wrra+ ty) (34k) '
<br /> CIO �nay „�9.edt i; /.{.� / /L — 1.
<br /> F-C D )C... ,Gl -s! !AT .� ISM L D RS SI AT DRESS
<br /> w .Ii'--t ,.� �_ __
<br /> T�gt1 1 411E TO BE A TRUE COPY OF AN ORIGINAL " .•
<br /> C I .° •'F s a Fry'WE THE STATE DEPARTMENT OF HEALTH,
<br /> •� ' ' 7y S TISTICS, WHICH IS THE LEGAL DEPOSITORY
<br /> FOR IT S.
<br /> DIRECTOR OF S ATI6TICS�D ASSISTANT STATE REGISTRAR .
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<br /> LINCOLN; NEBRASKA Issued April 30, 1954
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<br /> i1/ 6.6e, /y I ae L�(,U?_a-t., •
<br /> �/ / D�Q. 3. G d Cl�l�6" e' .
<br /> /_ - 3. v 5
<br /> .tale of Nebraska }
<br /> Cti -,u • of Hall ss .
<br /> E :._cc on N'arnerical I*-dc;c a,_.s r_'
<br /> for .e.::rd 'r. Office of 11e zte' ni
<br /> Dee:. ti -_1 day cl
<br /> __Nay .. 19_5_14-__ at 10
<br /> o'c_`cci: ;'- r'
<br /> aed T s.c•,_-fed in Ecok 1
<br /> Miscel. at page_- li
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<br /> Register cf Deeds
<br /> By. .
<br /> Deputy
<br /> Fees $2.5Q
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