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STAR or NEBRASKA
<br /> DRPAKIIERNw OF REAL=
<br /> NOB=41 KW Statades .
<br /> . I
<br /> STANDARD CERTIFICATE OF DEATH
<br /> ‘• DEPARTMENT OF COMMERCE
<br /> .t, MUGU OF THE MIMS 1_664
<br /> Rada Seeenier No....-.-----.. - -
<br /> I.0...0
<br /> PLACE OF DEATH: I 2.USUAL RESIDENCE OF DECEASED,
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<br /> hall debr, dall
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<br /> m me a 1,,mea--.Qiedk,....ea•fte•iiii:i••••• ! (d)/73.'d r' 0—' --
<br /> (d)Loath of Mane In hospital or InalltatkIn_.------ ..._ (0).--if h....i....t..,l..p to U.8.A., _ _ ...._ ....„..,...
<br /> a...m.4— 13_9__Year 8
<br /> (Simelle b.thor era.moo.or dem) MEDICAL CERTIFICATION
<br /> A r•
<br /> 20.Date of death.
<br /> 'eV.)PULL NAMIL-__LI).3hae __•1,, )•arei ---- -- boor _L — -
<br /> -- ilz...•certify that I.n. s....t.4_-
<br /> 00 If ester..
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<br /> t"t death occurred no tbe dato and Near Mated above Duration
<br /> III\11 4 Re 4.1s. . 7,rassihile_l davand../Ala rr 1P/I_ ,„„..g.p. ,
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<br /> 1 P(b/1 N. of or'U. li(e)Aim of husband ce
<br /> 1 7.Moth date of ammma Pt! "1-6714".
<br /> Ta.)-do- _ -Tia-o Ii-
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<br /> 11.AGE)Yesra 1 Menthe I Dare If km than one der
<br /> 75 5 5
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<br /> t■ ,,.maw..auburn 1 11 (Inched". an within 3 en nth I death E.Hysic.,A.N
<br /> (CMG 4.4 en=mkt> (State or foreign country)
<br /> 10.Usual occomation....-.1e .1.reu rarmer la-•11),,ii1).1,-: _ Underlie..
<br /> which death
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<br /> 14 Madam mune- 117q13.115*t h IA4 i B ______ _ __
<br /> 1 i ,,,,Bh.th„, ..0%." lee],p.14.. 20.21 death were doe to extemal causes.fill In the folloainn
<br /> NI (Mr,omen,or tr) ( m mei.moots,/ (e)Accident.miclde.or homicide Oozy le,
<br /> fle)Addeo.,_ .1,
<br /> - --- - (e)Where did Inver,occur? (cit.,or,.., ) (c.,,,,,) (Lot,)
<br /> (Dona),cremation or mama)) , (Month) (& (Tem) (d)Did Infos,occur In aveast holm.on farm,In indartriel door in
<br /> i (e)Pima)burial e.aretnattor-ti•e_.(:swag,-eme ,..4.-v.,
<br /> It d a)Sienatorn of It mal or - .4 OA.C••••. .
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<br /> ‘'ati ....E J,, Rebr • yd. iiiii,_ 1,‘(e) ii.s of Inlory
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<br /> THIS :VA, 'VIES,THE Arze TO BE A TRUE COPY OF AN ORIGINAL
<br /> CERTI`FA ONIF Ip■WITH THE STATE DEPARTMENT OF HEALTH,
<br /> BUREAtip. . • tkrA.T.ISTICS, WHICH IS THE LEGAL DEPOSITORY
<br /> FOR VITi!kr,t,t*I4EBtS.. -
<br /> ‘,e).,,,,;•:-,-,--
<br /> DIRECTOR OF ITAL S ' TICS AND ASSISTANT STATE REGISTRAR
<br /> LINCOLN, NEBRASKA Issued May 19, 1954
<br /> 4.4.4; /-..//7
<br /> CERTIFICATE OF DEATH o/d/JP
<br /> L. .....-,...,0-e
<br /> 7
<br /> DE' T. OF HEALTH, CT ATE OF "E--T.AcKA fi
<br /> HICHARL J. C A,RFY
<br /> Mate of Nebraska
<br /> ss
<br /> County of Hall
<br /> z..tered on Numerical Index and filed
<br /> .c
<br /> record in Office\ of Register of
<br /> ...L,
<br /> on the day of
<br /> May 1°51', at 2
<br /> ,_!.o,_-_, an..1 minutes P• M.
<br /> 1 ccc,rdec.: in k";cc„:-> ___J. __ of
<br /> <,-_t pa_cref;x2. _:
<br /> .a." C1=.1-2..-.0.•
<br /> i,e,gister of Deeds
<br /> By
<br /> 2.25 ,,,,Deputy
<br /> J ,•
<br /> Fees $
<br /> _
<br />
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