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IIPIIS]42IVS)REV.<-e STATE OF NEBRASKA • +i `r
<br /> FenERAL SECURITY AC�r^CY DEPARTMENT OF HEALTH
<br /> . FI:BWC Y.E.\LTO SEllS 1C:. Bureau at Vital Statietlas `1 J ,
<br /> I BIRTH so. 126..._... CERTIFICATE OF DEATH STATE FILE N
<br /> I Ni,PLACE OF DEATH U .
<br /> 2 7 S A RESIDENCE IWhv da 1< d il,,d. If ..I[Oaon:res lance
<br /> ii a.COUNTY
<br /> hall ' -.:!,'• STATE 1,- S.COUNTY Edo,..ddWoal.
<br /> p Nebraska - —
<br /> ) b.CITY III oue..lde 1'o,nra:o Ilmite.write Awal)lc$1'LEN COybT n UF' r.CITY III oute!de mrnor.t.I.a i,awl,I DAL)
<br /> TOWN Donl.nhan Itr fP-71iF•IR 1 TON. oniphan
<br /> I F I 1 F(1f of In has .dd et d.STREET' (If r y Qi.e locvicO)
<br /> T. II Loa y �a I "m"'"2,`- east-2 mi. so. or on1Filan
<br /> L.o,aI TION east 2,-so. oY ohlj/RatF_-- -----_----_ _
<br /> 1 1-N•MIr•OF • (First) t b.ldfiddds) c..ILart)- t 6.DATE (Month) IOW (Year)
<br /> DEf EASED •- Clara C. Bond I Det'.'wT,I 1+0V. 18,19 52
<br /> SEX 6.COLOR or EACH 1.MARRIED,NEVER MARF.IEI, l F.I..,E OF BIRTH 9,Ase IIn yrt if Ucder 1 Yr.III I'nder;61,15.
<br /> WII OWED DIVORUEI (Spectre)
<br /> bir 1 V' U. F(ure Min.
<br /> • erale I ■.h> e :AU ied Dune 15�1itIS! 1' t g
<br /> _
<br /> F• 1 y;..LS5r.�I,OCCLI TIU (Give l d f k'.Nh RIND OF I 1 INF,:11 !!H•clu It r - [r e 1 544 I!.CITIZEN OF W1LAT
<br /> E dace EYtigglireo¢li"' I `')I none URL`,ILSC1t0 I . UIb1L Voun. ,r Ire U[ • lJ ON4.TR.i
<br /> F THLR N/AlA1SC a.MOTHER'S MAIDEN NAME 1.1 h NAME OF HUSBAND OR WIFE
<br /> • IJa l Smith ( Nancy Carpenter _ (Charles s• Bond
<br /> • I Io.1 S I 1 EAS3.D EVER IY I1.S.ARMED F[li10ESI 16.SOCIAL SECURITY N.i5FORMANT'S NAME or 21enaturo&Addrees
<br /> f tY,en, �4nowmI u ,e,..-.r nr d , f.e : )II "I L, BO11d_i Iioni_phan,Nebr.
<br /> t ot DEATH ---- UF:I9I1,4 I.(I PI:FIF I)ATIO\ ---- -- 1 sl w
<br /> -32 r.ef rr Iwl h ".n."'(1') 1 DISF t, 1R lU.I1TIU\' - d ath -
<br /> UIREC'I'LY Lk..ADINI:TU nF;ATii• ' iks.,
<br /> • C• '• tll •rh!,e...wat th.i .bYTCCZUEh-r c.\L,t-s -��,f i y 12
<br /> -• ale of d91n[,m.uah DUE TO it .1 ,,.
<br /> hest (.Ilan. ••10,0.. .91,15)d ondltlen.,It■ anr.trI.In[
<br /> -p II r,n. the dl.- the to erl ako.e taut t.
<br /> _ e,which,ea ed 11 he underlrin[tau.W t T iii _.....
<br /> Inn which ceased d h _ - - -.-.. - - _- - _ —_—_
<br /> -,< II IITNER SIGNIFICANT bt) t' 'I DTI - of I
<br /> fo11yI to. a dt•eu In r to the death b,n
<br /> `-j I [va.1-_. ___ _ related to she dise.se or condition cans,.de•t4. —._
<br /> - __
<br /> i AlE OF OFERA- I .:d AJt9R F1.YDINI.S OF OPEE,TION ]0.AUTOPSY'
<br /> - Ye,1 N'a?.I
<br /> E ---- _-- )
<br /> e.sI Id UF:N'r I_Irc!fvl 316.1'I..\CE ct INJURY e ,t idle In r alum 21c.II rural OR Tt9{YN) (COUNTY) (STATE)
<br /> I II:ICU hum< (mum.I.c[or I.I,r..t,of,rc bldR. etc.) III rural.ray woo.ItUR\I,)
<br /> • - IIIO dtlt'11�F.
<br /> $ ?e 21d.'TIME IMOOth1 IDayl (Year) (How) 1 'JURY OCCURItED Itf.HOW DID INJURY OCCUR')
<br /> �E i OF 11hi1.a \Y u
<br /> INJURY m. Not Wh I .l Work Li )
<br /> ■5 C 2x.7 hereby certify th't:I ntt■r:ded the deceased frorr =—/ 1.W'', ..,to h ..1..:! .,1Al r0.,that I It sate the de-
<br /> - eeastrt 51511''.,, , ,)...5 is,..�_ add that death occurred at�1..:, nt.,from the catucs,atoi on the daft stated abore.
<br /> ' 2 SI YATIeR1, (,,epee• tl15) 215.ADDRESS / 2 e.UATE SIGNED
<br /> L, i f r ray(u L' t <t I/� >1/ �.�
<br /> 24. I 51'.I '.1 I I NAME OF CEMETERY OR CREMATORY 26d.LOCATION(Clty,town,or county) (State)
<br /> .= TI)))..; 1"...):J-.11. 6 I '
<br /> :€ v. ^ ,L.ICS It eslar V 1'w Ce cry I Bon:.R SIGNATURE
<br /> ilebrasva
<br /> A D:tTE sih"'D yv Li ,(.I IF\I:`'_'i:h;7 Ii' 25.FUNERAL U RECTOR'S SI NATURE ADDRESS
<br /> a "1,/ A_..'_ I lei minc'st on-butler 11011.,oA
<br /> 0 :II-==-----{= = I -_=5 'mss ngs, ,,e a _
<br /> C 1:11%eE .1 - `+1 • :1 'I'O BE A TRUE COPY OF AN ORIGINAL
<br /> 12: THE STATE DEPARTMENT OF HEALTH.
<br /> •B '+,'�.Iva •• at � .ICS, WHICH IS THE LEGAL DEPOSITORY•
<br /> FORA r a ti• /
<br /> "`` .,.2�,,��' '' . / ,f, . //.
<br /> •Y.• '.`ECTOR OF ITAL S ATI•TICS AND ASSISTANT STATE REGISTRAR
<br /> LINCOLN, NEBRASKA
<br /> 91 / ,iz •`,2.Z - 9 - q
<br /> i
<br /> •
<br /> State of Nebraska 1
<br /> as
<br /> County of Hall
<br /> Entered on Numerical Index and filed
<br /> for record in Office of Register of
<br /> Dee on the ____1_Q day of
<br /> 19 C. at /�..
<br /> o'cl k and ___. minutes_R1.M.
<br /> and recorded in rook / of
<br /> - nettk-r—se- atpage
<br /> Register of Deeds
<br /> 2 s— Deputy
<br /> Fees $ ------
<br />
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