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01 PHFLla2(VR)REV.41S I9TATE OF NF.BSsABBA
<br /> F'EDF"RAL SECURITY AGENCY DEPARTMENT OF f1EALTH
<br /> PUBLIC'HEALTH SERVICE
<br /> I' Bureau of Weal StaDat Ire ,
<br /> 1
<br /> �I 11111T11 N) 126 CERTIFICATE OF Di 1TrI NU
<br /> o Y ,PLACE—DR DEATH --- - _--- .RS UAL'RUSH,'NCE 5 +r - Lvai It I I ln„ It.--
<br /> n.CUL TY U ,
<br /> ,r b.CITY(It outside rr Ilmito write RoreU LE N G II O c.(I[Y If c ,u Iin write RURAL,
<br /> --- -
<br /> il TOWN 02 CI _ i,.,, ISTa l'n this,Dlecri.l 1
<br /> 55 J l I
<br /> !I.I,1 "CI NAME ,F tII i In Dirt,. t.,. .1 1 Tl)lI 1If rural,b e x ilea) -----
<br /> • 1 IIITLTIONt cit.,:
<br /> _ or i anon) ADDRESS HESS -
<br /> ].NAME OF )
<br /> DECEASED l}Ir.l) b 1111,;.11 (L )-- 1 f 1 1TF (M b) Dry) (Yrer)
<br /> AEI A �- ._ _. OF
<br /> ,1 _ (T or Pilot/ ...L __ f f E1T11
<br /> J.SEX 14.001,18 or RA( MARRIED.NEVER 511RRIEU .v DATE Olin!.1 9.A (t If L dr 1 Y.IIf C )Ira
<br /> 7 F 1 ' -t f, V.II wrl 1(l of c}1 ( 7)I b(.)hd )� M 1 )r"))'' .,..n
<br /> 1 I t 1
<br /> S ion 1 I\t 111TION Ci L I f k oh RIND r 1 ., 1,I,ILIH /1( ^- 1 IS a:13 C,,,, F.,(F WHAT
<br /> n,aurion ro,t of wor2lny lift ern if r,tiropi OR INDUSTRY 1 PLACE or f ,1 anti;) I COUNTRY',
<br /> 11
<br /> 1 1 ,Il C.:_fC _;tilt —._—_ L ,t n
<br /> :.F T)IEIf S NAME 11 MOTHER MAII£N NAME I16 NAME( IILSBAND OR MIFF:
<br /> 'T^ F PC
<br /> k 1...WAS DECEASED.EASED EVER IN U. ARMED FORCES ,II.SOCIAL SE UI ITY' ,.INFOI ANT'S-NAME^r 9,k L., -_--
<br /> .Yea r unkna )Ilt gi dote of rer.lre) 10.1 1
<br /> ., v,CA), (} 1 FAfH MEDIC,IL('ERA I I('_TII)N - -
<br /> \31 Ent Ar , I I.DISEASE OR CONI.ITION
<br /> lint for ) ,h),eaJ(e) llIRECl'LY LEAUII:C TO DF:ATII•
<br /> teen the ANTECEDENT CAUSES ,
<br /> Z weds lot*Lit r';'.' e. DUE TO II,1. -_.._.._ _._...
<br /> Neer fellvre, ..theme, Morbid c.ndltlon.,If any,gleing -- -
<br /> ::2c etc. It man. the die- rise to III shoe.feet. e)elati
<br /> , :,,' :I 7.",..mitt,,or temellce_' the ender)nleg tease IuL drg
<br /> 1 which ce¢sed dtelh.
<br /> )))'F)
<br /> U £;T" "1
<br /> :'<r IL OTHER SIGNIFICANT CONDITIONS -_
<br /> Oons contributing n¢to he death t not i related to the dm...
<br /> or condnlon causing.lath
<br /> J i DATE OF OPF7H0A N 195.MAJOR FINDINGS rte OPER\TtON .4LTOPSY"22 31J,= CAI k:NT' (sueei:y) 31 li.r.CE OF INJURY( r about 1 ,11, I T t,,, (COI;`.TY) (STATC)
<br /> SI I I E h m,C.o. ,+t ffct bldg.,et I: If ru v r I'LI:1r,
<br /> 3IO ItCiI'o:
<br /> 31d.1IINFIE (]1u F) Way) (Yea,) Moor) 211 INJURY kCCURRE) .II,,,till• ISO RS - CI::
<br /> _ INJURY, �.s ',.:e\'191 .tN^.5i-
<br /> l 33!ID: by c r ify that!utteActeS the de,r J 1 .... t
<br /> J It t- t eau de-
<br /> ; l r -on tJ and thul d an It /rot,tic r,o a ,,
<br /> n, [ t- tt.ri rthr,,
<br /> II e.SIGNATURE --- I Ih( E
<br /> jib. IDI . 1 F
<br /> D CE CV,,
<br /> 21 BURIAI DREM A=lob.HATE Mf.,)F E IT..I:1(I 1 .0.SI,!H d I,,n.i , ,..... n.n)I/(Site)
<br /> 1 THIN, RE..toyAL(Spa If)I1
<br /> I)D:1TE RE'D BY IACAL t R£C'STY 1P,'S SIC`'1TL t o' 1 � _---
<br /> Ra1 Si.Fl1E{ 1.lit FITUI 1f :;£ 11 DRESS
<br /> -;' 1 0. f �.n,,��ge ft
<br /> T's X F TIFIES� H!r A 7✓t-TO BE A TRUE COPY OF AN ORIGINAL
<br /> CE•:-4 • -ATE ON FI r THE STATE DEPARTMENT OF HEALTH,
<br /> BU r 6-OF VITAL S. WHICH IS THE LEGAL DEPOSITORY
<br /> FO 'At.,RECORDO. ..
<br /> •
<br /> S ATI•TICS AND ASSISTANT STATE REGISTRAR
<br /> fr EBRASKA
<br /> V
<br /> \./.
<br /> S trte of Nebraska ?
<br /> SS
<br /> ;.lire"-:; on `r HT eYR(at lydes awe?filed
<br /> L..a' Yci: Y`s, Ha. ..•f{,.^� 4 £-g ter of
<br /> an .: day of -
<br /> c 3 of
<br /> Register Deeds
<br /> By
<br /> ,Q 6— Deputy
<br /> Fees $t-----
<br /> nom_-i''
<br />
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