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<br /> onset NO.121__ CERTIFICATTE'OF•DEATH EYATEMEMC. ` ,
<br /> L)`LACE OF WEAVE it USUAL tHUIHENCE(What.dw�.....4
<br /> I a.:COUNTY.:110.�I A., ZL iitTEe °MO/I Mi.R,,.kn).: .,
<br /> J._tj` •-CITY(tt wWd.`......f/.wat.wW WWaAY1W GT E or a.-CITY(u wW4e.ww{r.t.F.A.,R. `.� -
<br /> k TOWN C,..rd Lyf4Yt0 ./' it AL s t =---:' -i-t,• - .
<br /> TOWN REP RR
<br /> 1 d.PULL NAME OP(te oat At horyh.I.or hatleatkc.`,Mao atm(.dd.M.. L STREET (U.p 1.fir. .' -
<br /> -I[OSPITAL OR SE .ft.'1h6 s S ReEP O0°)� AO/awl I * lairW 1. W M fa-
<br /> IN31'ITUTION
<br /> I f.NAME OF (YAW) A(I ) yy a( ) I.DATE tU (Dry) Ow)
<br /> I ` DECEASED ) ued� Af° I f L�• I DEATH f ,2� 'J 2.
<br /> yf•,SEZ I.COLOR 7.MAggf�,.NEVER MARBt1�, :327.OP!,..,s,1 IRTE f.Af.�(T.fin.H U 5!..H ud.r 24 U.
<br /> ' 7IlA..f fir'I y�� WIDORED.DIVORCED IFVatUJ) A_ ..t� Iwt t�)I Mn.__�3Mf..�Hoae.1 Ml..
<br /> It..USNAL OCCUPATION(((Voo kW of 110.KIND OF'BUSINESS 11.BIRTH-(Gies.town county)(elm.If.CITIZEN OF WHAT
<br /> lbw dwloa moat o! ktef W�ayW a ) OB INDUSTRY P i w •try) CO LT
<br /> I /'Y. la. ef°° (MT ::.I ..
<br /> It FATHER'S-NAME_ N..MOTaHE.kW.�S�MAIDEN NAME IS/►NAM-OF HUSBAND OR WIFE
<br /> ..L !'1701 A.A. Simoha7'YreY1: (V.tkn1..o..) I Else,. M}c.La s i' .;,,
<br /> LIN WElp DECEASED EVER IN U,S ARMED PORCEST+IL SOCIAL SECURITY INPORMAy A
<br /> ee COL tmk.ow.)'(H Wo.fay.taw or data.of tar•)s„ NO.I /t" tsM¢`i S4I1l�.-/ •
<br /> Oy -M.CAUSE OF-.DEATH MEDICAL ERTIFICA N 'J Wbnat&Mama
<br /> a mtm only caw wow w Oe.et aW DuO.
<br /> h j. tine fo.(g) 04 Ihy...gm.g) 1.'DDrSEASEYOR CONor 20 DEATH?RECttr
<br /> ( °TIE dor mot m...Wok `ANTECEDENT CAUSES .ova TO.(b
<br /> e It tM MatNf e.ditM..1(ar-.fa.te[
<br /> '�(6y�t,,�r
<br /> rho to Ur.W.sus(a)matte[ V ,
<br /> o Goa 0s ea.wIthdt carol
<br /> w 11e.- the.ud.Wte.e.ar Coat. I1VE TO fe)...
<br /> /(t, _ . II.OCHER.SIGNIFICANT.CONDITIONS
<br /> i v f/y Ca.dltbn AeaI.lbMI f b th.da.th b.t not
<br /> niat. b tM dM...m a nditlaa eaa.in.fr.tk. _
<br /> If..DATE OP 01111 If..MAJOR FINDINGS OP OPERATION U.AUTOPSY?
<br /> T10N� 1
<br /> 21..ACCIDENT ,(Sndy) I fah.PLACE 09-INJURY(....teat.Loot 7Ir.(CITY OR TOWN) '(COUNTY) (STATE)
<br /> SUICIDE home,1..I sT.KI I,o(Doo►M...ow.) (U at...write RURAL)
<br /> fed.TIME (Mouth) (Da.) fY.w} "fHow)�llo.INJURY OCCUERffif 215.HOW DID INJURY OCCUR?
<br /> JU - NM L4 Work B
<br /> .INJi}RY Na.Wbfk�alt
<br /> 4 7f.j JisIsb l c'e7Nfy t 1 the deceased ham.!.... } 943'to 9'.2-7 19I�.,that z Taft paw the de-
<br /> Ceased alive on. �:/_ Y and that death xelmred at./�.. ,
<br /> tn.from the taJus eS,and on'64 date
<br /> statedT above.
<br /> fiL`�'67 'SSy/ (D.pyt/S/titM�Lk '
<br /> M B AL CC i{E X A MA DATE, 111-a/NKIE OF GENET Y OR C E E M A T O R Y 7/d,.(j f g C A L OO N(CI .Away or coed ( )•14 OPAL i.. 'I 1�C d 1....ry /►'Sty 4"
<br /> '' DATE D BY-UT-a- V�1STRAR'S SIGN RE / �i L 15.DUN+' D COO .. -
<br /> THIS CERTIFIES THE ABOVE TO BE A TRUE COPY OF AN ORIGINAL
<br /> -CERTIFICATE ON FIJ.E•WITH THE S'ATE DEPARTMENT OF HEALTH,
<br /> -IUFF:AU OF VLTAI RTATISTICS. WHICH IS THE LEGAL DEPOSITORY ,
<br /> !4R VITAL RECORDS,
<br /> _ � �
<br /> - DIRECTOR OF ITAL S ATIS7ICS AND ASSISTANT STATE REGISTRAR
<br /> LINCOLN, NEBRASKA _ Issued Orfober 13'-11955 -
<br /> •
<br /> tea
<br /> ,
<br /> ''IEA'TH CE:.TIFICATE
<br /> State of Nebraska Department
<br /> Of Health
<br /> to
<br /> John L. Archer
<br /> •
<br /> C.'4^`z: of Nob-ask-
<br /> (2(...,r...:-.-c--- -....f .a_gi R '
<br /> .. :I . .. _ racilf ice -' d filed
<br /> l,:r r .,-.1 43 -?f'17;,....�tr 1.-.,..egi:„:_..,r. Tij
<br /> November 55_._,_,_ ,� ,f
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<br /> . . O:_, .__a-. 15 1:.,.;'-'.._t -g: °
<br /> 3 ;fro
<br /> __.2:4i- -c-.v• -_
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<br /> a_ -�ester OS SicCC13
<br /> Fees S j
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