|
IIisn�L B�)CItUiEv�.wf STATZ OF N�AB[A • �S ,,
<br /> PUBLIC NEALTR>� CT DZPAZTMEll'r OF HEALTH 1
<br /> Bureau td V!W 81RIYtlaS 51-004931 2. r
<br /> intern NB. Izs.__. NO.
<br /> CERTIFICATE OF DEATH STATE Flu NO.
<br /> ■ PLACE OF BEATE 2.USUAL RESIDENCE(AM w 11.11.dae� d 11.11. I If aithat e:miaow
<br /> 'OUNTY
<br /> Ilia 11 _ . RATE .• c •COUNTY .dWa).
<br /> G.CITY of wLU. -- — H.1 7 -
<br /> rorFer.4 IIeJy.errly E.rY)I,�L E N G T N O a QT'7(II oot.Ya t�V Ilvy RII.RURAL)
<br /> K�
<br /> r11WN Gri.nd 1 ],Il(• TAY Ile Isla des) OE 1 TOWN d !'1.11.HARK UI'(II oat,.ba,F,w or Ia.GLIU a;..n,�t.ed.�. `STREW rd 7 S 1 i n[i
<br /> IIt.S.IT L OH (H ranl.gin bslb) i
<br /> X In SIIICTION =t. Fr.-r,cis r±'0$ or 4s.Uo.) ADDRESS ]
<br /> I NAME-OF -a,w:,,
<br /> •08 4 est 11th j treet _ , .t
<br /> DID F.ASED
<br /> L IYidd41 a 11.w) 4.DATE (Meath) (Dy) (Yav) '.y`t'
<br /> a w1rm) Ik.bJe
<br /> Fubv A"eYers DBATM 5 18 5,.
<br /> S SYS s'COLOR w EAC ).HARMED,NKV KRYANItIED I.DATE OF BIRTH'I.A
<br /> WIDOWL'U UIVUHCYII IStr rdy)I n(L fi It Under 1 Tr.It o.dar 24 Rra
<br /> y t Q'J QI {•.-1�� I that birthday)2__I Boa. I_ Nou.• Yln
<br /> •r t a: work lab ie� ?-20-1 Rig 72
<br /> � MLA IGIn kind of wWk lab.KIND D' I I I.SINIW)I I.NINTII-
<br /> 3 Jaw J �y" 1 71;75 lit.ewe;1,et,r,d) Gitr,town w auarr) IlK.taill.couu N OF WHAT
<br /> ,E nr'),A NAME ITP I-- OR INDUSTRY PLACE Iwe a.avu.trrl COUNTRYT --ii
<br /> ■ 1 II.FATHER'S NAME I$p RAP` OT'PTigOt.NA- II E I ---iii
<br /> t ' I.a YUTUER'21 MAIDEN NAME I IJA NAME OF HUSBAND OR WIPE
<br /> ill ':-G,es Lording__ I G —i
<br /> ARMED Foberts Edr4rd J. Meyers
<br /> -'
<br /> a
<br /> Z jI.WAS DEI.'RRAeSRI)EVER IN U.H ARMED FORCES? IC SOCIAL SECUErrY IT.INFOIIMAIITS NAME w
<br /> IY... .bo.."11 It.,e..wr ICt*«IM.Na) NO. GrLnd•I;lz 'a_
<br /> \U F• J. Leyers, Grind Island -,
<br /> d II CAUSE OF'DEATH
<br /> M enter may S16DlCAL CERTIFICATION 6e.n.1 btws
<br /> a Iw•lal.,b).•e.d le) I.DISEASE OR LEADING CONDITION 1 1 De.IL
<br /> pM 1, ANTECEDE LEADING TO DGTH• - _
<br /> m \� 1.1-_. _-.____ _
<br /> b •TLY daea wN Mw 1M ANTECEDENT CA USER 77
<br /> A a ■\I LZO{ I.L 1 :,-*is DUE TO (b) X-,
<br /> t\ .,r. n ...... w dlr Ya.Md ad)a....H w.d.la
<br /> ` 1 Ibe• \k#u•���!!' lb.y�•rbl.F::.........1r•SINN i
<br /> '• II ••d°A'� DUE TO rrl
<br /> II.OTHER SIGNIFICANT CONDITIONS
<br /> ------ -- - ---_- -- -t_I
<br /> Y: GWltla.a rantrlk.tbt I.W M.J 2::„-«. _-,_;
<br /> M rtl„M,a,M dMU•r re.tit rw t
<br /> If 1 'E OF OPERA It►MAJOR I••INUINGS OF OPERATION
<br /> t"I TIONi Nat.AUTOPSYI t
<br /> 2I..ACCIDENT II Ye.0 No GI
<br /> ISDad4) Ilk,SILAGE OF INJURY le.It tow 'I'd!GII'E OR TOWN
<br /> F SUICIDE borwe,,arm,tart.,.....NIIw bldIr ea) rural ) (COUNTY) (STATE)
<br /> i HOMICIDE .,'aa wrl,e RURAL)
<br /> t 7 2Nd.TIYH (Mo.tL) (Dar) (Year) (ROO,)I II..INJURY OCCURRED 211.HOW DID INJURY OCCUR?
<br /> a OF W6;M at Wwk
<br /> , q INJURY Not WWI.at Work D ',._
<br /> C r_
<br /> x :S.r hereby certify that r attended the deceased from 11 ...C...Y._.,19 51,to...
<br /> eea.ca aline o S-IS.19 S/,and that death occurred u I .195..,that I lost saw the de-
<br /> -m.,from the cawed and on the dote staled above. _-R
<br /> i]a.914NATUR6 j (Nom or t/.) III ADUTESS
<br /> If..DATE SIGNED
<br /> c Ha.BURIAL •t: E321�Nb.i)A IE I24 FT,EYET 1 fYE CN A ORYI NI t 2.r....31
<br /> • lIDN, EMItVnL iSlxclh) bwa.w toasty/ 181.u) N
<br /> i F'te.:,oy� 1 :-«mil GTeer1•OUG Cec,etery
<br /> ., a DATEREL'11BY'WCAI IAEU.TS..GGSIGN TURN �eY8TU °eL A Dkn
<br /> 4, A 125.FUNERAL DIBECI'OR'S SIGNATURE. ADDRESS
<br /> :v oo "� Living:.ton-;ondcrr,...,.,a
<br /> �I --.-vim_• _ w"- _ Cr..Gr ,-:d Is]<.nd � ,s
<br /> _ tiebrteka '
<br /> THIS CER:11F :s TIIE AIi VETO BE A TRUE COPY OF AN ORIGINAL
<br /> CERTIFIgyE N PILE ITII-TJIE STATE DEPARTMENT OF HEALTH,
<br /> B UREAU'IO�+';v,I ATIS-1'IES, WHICH IS THE LEGAL DEPOSITORY
<br /> FOR VITAL, -
<br /> RItcOHI�S`',t'.
<br /> DIRECTOR OF ITAL S ATI•TICS AND ASSISTANT STATE REGISTRAR
<br /> LINCOLN, NEBRASKA
<br /> ISS'It Ot tobt'^ 28, 1,55
<br /> 2
<br /> is may'.
<br /> DEATH CERTIFICATE
<br /> Mable Ruby Meyers
<br /> ct-.n of Nebraska 7
<br /> only of T i 1! ss
<br /> Enter-d.on N-:me^ca4 ft),'.,,:_ are!fi..ed
<br /> ;';t=: of _c .s>.er cr
<br /> Ea, 17,rec:;: _ _
<br /> Deeds on he ___ 31_ __ -._ ea./ or<
<br /> October i=+ 55_ . 1
<br /> . . r P. :.o clocat N_,u 3o r �; . .
<br /> and rt.curied ,o `.c lr. __3 of
<br /> Miscel. d+ pa:,.:.._. z .
<br /> Cast-� __--
<br /> .'.ZIr..ter at 1_e(.�cis
<br /> Feed $225 t3eputy
<br /> ,Bev. Q.4..6. 4.
<br />
|