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',i ' Lot 2 , 510c'r' 94 l k.ri .'-r a1 own, no;ii ,2ity , of Grand Island , Sn-a
<br /> j, PHS-798(VS)REV.7-63 STATE OF NEBRASKAPY• i� -' �
<br /> IS DEPARTMENT OF PUBLIC HEALTH, DEPARTMENT OF HEALT t ��1��(//.- �<-t '
<br /> m EDUCATION AND WELFARE Bureau of Vital Statistics ! (Glenn ri.- Ged,dea
<br /> 4 BIRTH NO. 126 CERTIFICATE OF DEATH STATE FILE NO
<br /> 1. PLACE OF DEATH 2. USUAL RESIDENCE (Where deceased lived. If institution: residence
<br /> �i a. COUNTY Hall a. STATE Nebr b. COUNTY Halelore admission).
<br /> .. try - (-
<br /> _ O Cell b. CITY (If outside corporate limits,write Rural)1 c. L E N G T H OF i c. CITY (If outside corporate limits, write RURAL)
<br /> Q• wit TOWN Grand Island IST 5 yrs 1 TOOWN Grand Island.
<br /> W ., i d. FULL NAME OF (If not in hospital or Institution, give street d. STREET (If rural, give location)
<br /> o HOSPITAL OR address) ADDRESS
<br /> 4 ,. Z INSTITUTION 1021 West 4th St 413 East lgt
<br /> 3. NAME OF a. (First) b. (Middle) c. (Last) 4. DATE (Month) (Day) (Year)
<br /> q DECEASED
<br /> lexander Dwi ht Wri ht °I''
<br /> v_ a (Type or Print _ g _ - g DEATH Nov. 15.1954
<br /> 5. SEX i6. COLOR or RACE 7. MARRIED. NEVER MARRIED, 8. DATE OF BIRTH'9.AGE(In yrs.,If Under 1 Yr. [f Under 24 Hrs.
<br /> w
<br /> WIDOWED, IVORCED (Specify birthday)' M D. I Hours I Min.
<br /> W o Dale White Married et.9. 1873 7 y
<br /> tw�
<br /> 4 q II 10a. USUAL OCCUPATION (Give kind of work 1l0b. KIND OF BUSINESS 11. BIRTH- (City, town or county) (StateT12. CITIZEN OF WHAT
<br /> .] I done during most of working life,even if retired) OR INDUSTRY PLACE or foreign country) _COUNTRY?
<br /> __R_et-ired Carahop RR, C rman RR. Up _ Brooklyn N. Y. UX
<br /> a A x 1 13. FATHER'S NAME 14a. MOTHER'S MAIDEN NAME .
<br /> 146. NAME OF HUSBAND OR WIFE
<br /> H ? 4- LFrederiek Wright Mary Powell I3ertha Wright
<br /> a' a. O i I! 15. WAS DECEASED EVER IN U. S. ARMED FORCES? 1 16. SOCIAL SECURITY i 17. INFORMANT'S NAME or Signature & Address
<br /> r w C� Ye�T no, or unknown (If yes, give war or dates of service - NO. Bertha Wright, Grand Island
<br /> t ( 1V0 ( )
<br /> G MEDICAL CERTIFICATION n-c
<br /> Z °EW,1 18. CAUSE ,. DEATHS ATION Nebr. Interval Between
<br /> ,T,c Enter only one cause pet I I. DISEASE OR CONDITION
<br /> a a3 m 'II line for (a), (b), and (c), DIRECTLY LEADING TO DEATH. Onset and Death
<br /> M o_Wv (a) Cerebral artery Occlusion
<br /> R
<br /> s,�T., ICI `This does.not mean the ANTECEDENT CAUSES
<br /> •
<br /> wl a+ c a u lh mode of dying, such as! DUE TO (b) Art.e.rio$f;le rosin
<br /> Q -rp,r I, heart failure, asthenia, Morbid conditions, if any, giving
<br /> is w ,I etc. It means the dis- rise to the above cause
<br /> �" (a) stating
<br /> a-new I ease, injury, or complies- the underlying cause last. DUE TO (c) Hypeoprostrate
<br /> iz w w i' lion which caused death.
<br /> • c od0.. II. OTHER SIGNIFICANT CONDITIONS
<br /> y Conditions contributing to the death but not
<br /> ' o Oi a related to the disease or condition causing death.
<br /> w 0 W a)
<br /> �• E.0 19a. DATE OF OPERA- 196. MAJOR FINDINGS OF OPERATION 20. AUTOPSY?
<br /> (4 4-?,> 9 Z, TION
<br /> Q'i Al2 E r-lli Yes E Nor
<br /> • d,; °al. 21a. ACCIDENT (Specify) 21b. PLACE OF INJURY (e.g., in or about 21c. (CITY OR TOWN) (STATE)
<br /> c y i 1 i (COUNTY) (STATE
<br /> W� E SUICIDE ;home, farm, factory, street, office bldg., etc.); (If rural area, write RURAL)
<br /> 2 t a rill',_ _HOMICIDE
<br /> �' 'd a 3 21d. TIME (Month) (Day) (Year) (Hour),, 21 e. INJURY OCCURRED 2i{ HOW DII) INJURY OCCUR?
<br /> o E To OF While at Work ❑
<br /> A �.-. r t- INJURY m ! Not While at WWork❑
<br /> ,.o▪ K 22.1 hereby certify that I attended the deceased from S! ?l 19`5 , to 7l/ , 19 4 , that I last saw the de-
<br /> . E? w,r,( ceased alive on.11./1 rj. 1$4_-.,and that death occurred at..5...05n1.Plom the causes and on the date stated above.
<br /> 23a. SIGNATURE (Degree or title) 23b. ADDRESS 23c. DAT SIGNED
<br /> a• , K? F. MQ Dermott. MD Grand Island, Nebr X1/17/54
<br /> v 24a. BURIAL 2,4y DATE 4c. NAME OF CEMETERY OR CREMATORY 124d. LOCATION (City,town,or county) (State)
<br /> 4''.,' w a CREMATION ❑ Nov-.18/54 Grand Island k°emeter Grand Island, Nebr.
<br /> F.E x °u REMOVAL 0(Specify)I y
<br /> a .. .` DATE REC'D BY LOCAL REGISTRAR'S SIGNATURE 25..FUNERAL DIRECTOWS-;SIGNATURE ADDRESS
<br /> REG. !
<br /> • N INov.l8/54 F. S. White ::=.1 .- - c 1 -
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