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PHS-1.e(VS)REV,6-d8 STATE OF NEBRASKA
<br /> eeDER.1L SECURITY AGENCY DEPARTMENT OF HEALTH ' C T )
<br /> PUBLIC HEALTH SERVICE Bureau Of Vital 8frtbtlDS 5? c3 r q 3 4 2
<br /> RIRTII No 126..._. CERTIFICATE OF DEATH ELATE FILE NO.
<br /> I.1•LA(E OF D H /1/9 2.USUAL E E(Wham be.ued llv , If tntloot t.ddozo.
<br /> ..COUNTY ./. -{ STATE
<br /> - ,. ., b.COUNTY pa(On Megrim). ,
<br /> \ Q CITY(If o; YcorPOrate wr t) LENGTH OF c.CITY 11t ou corporaG limit.,}r)y rit) i�_
<br /> •) OR I r • AY(lo T 1 OF OR /.iL��((/L��Y-
<br /> TOWN net .�0A TOWN
<br /> A.Ft I.E.NA.NSF if o• in .,It.l or Mt tutlO.ai.c.tr.et ddreu U.STRREC (If rural,eye • on
<br /> R5P11AL OR 1�D`� bcalool ADDRESS Q
<br /> x I1: u rCnoH_ _ __ l y'I
<br /> 1 i.NA01F:OF (00.0) b.(Mid •) r a(L M) (,DA* (Mootb) (Dal) (Rae)
<br /> DECEASED
<br /> 3 (Teo.x Print) /7 ,1^ •� �I I DEATH /
<br /> -3'SEX 6 COI, RACE .MARRIED,NEV RR MARRIED 8.DA'E U'B1RT1h ..Am.(In lr IIt Uodao- 1 I Under 24 lire
<br /> ld o WIDOWED,UI VAC (Spcltr) 7 Imt blrt6tlay) Mo.. a�la Hours IOn.
<br /> -II4tUct.i_ � _ YZc�.ati•.�- •--1 /-:I/X,0 o,�/// /d
<br /> 1. \I. )CILI'ATION(Cl land of wurk 106.KIND 1 t DGSINESJ 11.BIRTH Wit,,tow A county) (8tat.12.CITIZEN OF WHAT
<br /> d ft k Ate If re ed) OH 1N '1
<br /> JTj�" _ _ 77,7//I�G4. Y F y rvlyo country) I COUNTRY?
<br /> is)F Ty% §NAME,) M'fJf'HLR9 MAID d �(b.NA LT3 OR WIFE
<br /> c )� I Y N s yZ l i f EVER IN 21 9 r ARM 1 FORCES'Ji 16.SOCIAL SECU NO 1 7? T;S`IIAB jor E1suM re k Addreed /.
<br /> 1 I SE OF 0E51'11 MEDI(''AL('EI(TIFI('ATION / ^_-- -7°-i--- 1 Between{Y/Qi
<br /> E
<br /> n chin '')•n 'm.an .II 1 I IVF\T OR cONI ITIUN ` Onset and Death
<br /> thus, 1+t
<br /> [iREITLY LF�1 IA.Tu UE\TII` - ,
<br /> •' 0 A'.TF.t EDENT('Al'E9 Q
<br /> II mme er ,d11n0, •arm .. Due•ru ,10 ..� ......
<br /> beats ftll urea ,h. 1.. ,,:,. mndltlen•,If 7,.tvina
<br /> -, n mmn. the dlf d.e m m•.boa.ma.e lai•.un. �N (�iJ' !y ��
<br /> :I e•se Inlur>,or ram011<• tM1e underlylnl e..0 WL .1 I!I- TO ,el
<br /> • uet. wM1lrh eau.ed deatk
<br /> 11 IYI'l1EH 91LNIFI(ANT(t tNI I'r1uM9
<br /> •
<br /> endiilon trlbotlna the death but not
<br /> related to the duteroe or condition thus..de b.
<br /> c Is..D.\I'E OF OPERUNA I ob.MAMA<FINDINGS OF OPERATION 20.AUTOPSY?
<br /> TI
<br /> I Yen 0 No
<br /> • -. ItIOENT ISpecify) 2Mb.I'IA,E OF INJURY tca..,in or about 21c.(CITY OR TOWN) (COUNTY) (STATE)
<br /> E ;I11101) b,me t.m.factory,street office bid..,etc.) (If rural are write RURAL)
<br /> _IIIM ICIt,E_
<br /> n 2Id 'TIME ITuoth) (IA,) IYear) (Rotm)I 21..INJURY OCCURIIEU 211,HOW DID INJURY OCCUR?
<br /> OF Wh N k
<br /> 1 INJURY NA NMI,y�Work�' AA--..-- I at
<br /> d 2 11 71/ ?tf5�(h�11a�ft'nd,d flu 1 .d f !LT/A ) 19 IJO to f2-,19.5.2 that I lost sato the de- t
<br /> r 1 tan on V}/2-19..7-, 1 that deaf Irn.ti u ( Ya •t1
<br /> (}— t d Q.,n..from? es undo 1 t/ dote rtun'd aLurc
<br /> Y SI ATURE�r t L ,(%,, (Dearth or It ) lib.ADU 28e,UAT IGNjiR
<br /> 1 2 RC RI1t( E M A 1, �TE - NAME OF CEMETIE Y OR CREMATORY 2(d. CATION.0 ) V5
<br /> - `UV, REMVA OC,I.1 Itke, r � y f l ! o�
<br /> TwL/y 1T�D Y L(]OC�L KRyJ SI'• L P RE �� tUrI�SA'L F Tr / / ,�1l
<br /> • VAUG L y` i '' 4 �r r . . � �kUNL'I-,- . - 9 81 d C (fie
<br /> -.------ . _ _______L._.._ ,,. ._ ._ /o, —
<br /> �, ,1 X13 1 r
<br /> T_l
<br /> THIS CEIi. °FIES THE Bp'PE;TO BE A TRUE COPY OF AN ORIGINAL
<br /> CERTI$'CA E ON FI WO/THE STATE DEPARTMENT OF HEALTH.
<br /> BUREAU,YVo TA §° IV'i'1tS, WHICH IS THE LEGAL DEPOSITORY
<br /> FOR VITAL. .,. '_. J
<br /> :1 r ////
<br /> DIRECTOR OF S ATI TICS AND ASSISTANT STATE REGISTRAR
<br /> LINCOLN, NEBRASKA
<br /> Issued August 25, 1954
<br /> at 2, /7 /b'. ', 3. ✓7-"''Ll G2
<br /> .lam /, z ' Y 7 fGv ^•.�... �`°
<br /> •,/A. 6t s r r'O 7 -VM - �—�
<br /> 24t'H
<br /> State of Nebraska }
<br /> SS
<br /> County of Hall
<br /> Entered on Numerical index and filed
<br /> for record in Office of Register of
<br /> Deeds on the ___p2_/______- day of
<br /> _x`1__ at _�Q,:
<br /> 19
<br /> o'cl and __! `-_minutes_ .M.
<br /> and recorded in Book / _� of
<br /> 2/1442-e£-6 a page---_
<br /> Register of Deeds
<br /> By
<br /> e•'
<br /> Deputy
<br /> Fees $' -----
<br /> s'7.?
<br />
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