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11 PAS-TOWS)REV.4 4 s��N _.. ((�\
<br /> I PUBLIC HEALTH SERVICE ' Bureau of Vital Statistics - -, Ili 1J 6
<br /> BIRTH NO 126._ CERTIFICATE OF DEATH STATE FILE NO
<br /> Q
<br /> +: I LACE F O DEATH 1 USUAL RESIDENCE(Where deceeeed heed. If inetltuuon.resider=
<br /> V n COUNTY BTATE,. 1 b COUNTY i before edmleelon).
<br /> \� b.CITY(If Wd W ate Dente
<br /> i1e Rural)le. LEN G T II OF e.CITY(If outside corporate halite, (te AURAL) 1
<br /> '` TOWN 1. STAY TOWN `"f
<br /> 1 .t.FULL NAME Of 1I, 0,0 in 00..0000 er . 0 d.SESAME (If el,glee location)
<br /> HOSPITAL OR - u °�.�.1 ADDRESS
<br /> x INSTITUTION "-:l .,:l_,F:s I
<br /> S —r NAMI:OF a(F au) b (Middle) e..(Last)
<br /> S 4.DE (Month/ (D )) (Year)
<br /> • DECEASED
<br /> Print) 81'10.11"11- T/ '_1 t7.0 i? DEATH II b4
<br /> SEX 6 COLOR or RACE 1.MARRIED,NEVER MARRIED II b DATE OF BIRTH I.Age(In Ire.if Under 1 Yr.If Under 24 lire
<br /> u. I _ WI1(OWEU DIVORCED(Specify)] ' ,. —J'C I leap ytrthdar)1 M 1 tlY, Hours 1 Min.
<br /> l E aaas - ..�
<br /> I ht O.L CI.LP\TI N(GI kind of work lob RIND 0/ III:SIYf 11 1111011 (City, county)/State,12.CITIZEN OF WHAT
<br /> 1 d of krr_ 1 f t morel OR INDUSTRY L PLACE of atrY) COUNTRY?e . mo'.:E t '_C_. r ° I S.
<br /> 1 In F\THEIt NAME 2 Q '1 1i MOTHER'S MAIDEN NAME lab.'NAME OF HUSBAND OR WIFE
<br /> 'O` !AS DECEASED FIVER IN U S ARMED FORCES 16 SOCIAL SECURITY IT 1\FORMANTS NAM£. &Addre;e
<br /> 2rl (Y p unknown)II f[Les,give war., d of eery II fiV I r y
<br /> .' t y C\U F OF DEATH MEDICAL.CEBTIF IC ITION f 'Inter I Between
<br /> G' *E,.for(n) ) d() t.DIES ISF.OR CONDITION % ° ' y H d Death
<br /> DIRECTLY LEADING TO DEATH" t� 40.a.t..aT 4
<br /> g ' I (.u_- L < jam/
<br /> • ANTECEDENT CAUSES ,.1/.'11,41.41/4-..
<br /> ,. „/111-14.1.12.41.4_4/.,/ ) �y
<br /> 8 mode lef not ..h�.' tut.TO l6r� !�S/•^iY's�. :/ of 'a.r
<br /> i
<br /> s heart ,were, IR. d .- r er to he=ee,i1 :,g1,Ng
<br /> 10/ . et< it mean. tke do.- rue to the ab u lnt
<br /> aemoHce n rase() let
<br /> 1 1 ar the anderlrmg taus Wt. to 1 TO
<br /> � h r�ceoxd death
<br /> • 11.OTHER contr aTrANT OONI11F•10'.S
<br /> R / Co-neatens he dime tin r to We de.I0 sax ndt cr {s
<br /> 3 related t<the e,se.0 or condition 00.00.a<,th. '.,.{,.I r o _•/_,,rj .. % _-< y I f�'(:
<br /> 190.DATE OF OPERA- lab.MAJOR FINDINGS OF OPERATION j 7',20.AUTOPSY�,i
<br /> : TIONl - 1 Yen❑ No x
<br /> S f_
<br /> T. a. OCCIDENT ISpecifr) 1 Stb.PLACE OF INJURY 1..g h
<br /> ..to or sut'21c.fCITY OR TOWN/ (COUNTY( ,STATE)
<br /> SI.'ICIDE I6ome,farm factor,street,office bldg.etc1- III rural area.write RURAL,
<br /> - HOMICIDE
<br /> • 21d.'TIME (Month) (Day) (Year) (Hon/) 1e.INJURY OCCUIIRED 211.(1,0W DID INJURY OCCUR' --_--
<br /> OF *0,la at Work L
<br /> INJURY - m.I Not Wylie at Work'L
<br /> -J: r
<br /> x 22.7 hereLy rrrtijy that I at�nPrd the derrased j m.�i!�'.'f.?.YI9 to.�:1•� /1 Iv ,that I loot saw liar dr,
<br /> c a ce./a/ r 001/2 yi,,Az"-,and that drat%off armed at.e5.LC Pm,from the and on the dal, stand tut','..,,RI,,tpMATURE Doe) I 231. A.EMALESS i 22r.DATE SIGNED
<br /> 2 to 0ud.11 1 240.D1 a0.NAME OF CEMETEryPY 011 CI0LMAT IY\,244.LOCATION((1.r. -roa0ty) (State)
<br /> CREMATION 0' I _/ /' V '/
<br /> • all REMOVAL i-,-,,r,f� �S ///�/Jj'S� /IC TF /YcLEV i A F)-...
<br /> 01 D.1TF.REG'D BY LOCAL fA RS Si IGt<# LrP'12E F'1}Ytli.\ I:EI.f !t'S SIGN Rif • "`^
<br /> ;�` , c......./ .�-�--,-
<br /> J; t k re� RRD 7—a f\IW 1/54;yam//yi
<br /> -�-- _ - `- 5e c- 2 3; w P (0: R (2 HO,"-- '
<br /> THI$ _ TIFIES THE AB9Vger0 E A TRUE COPY OF AN ORIGINAL
<br /> CE ICATE ON FILE WIT K THE STATE DEPARTMENT OF HEALTH,
<br /> B
<br /> BURErPytY.OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY
<br /> FOR V1151, RECORDS.' e
<br /> '\. QIK£ZTOR OF ITAL S ATI TICS AND ASSISTANT'STATE REGISTRAR
<br /> LINCOLN, NEBRASKA I.--art e \. \ , _`C,,( I
<br /> I
<br /> i
<br /> . I
<br /> II
<br /> i
<br /> ay-
<br /> DE,ri_TH CERTIFICATE
<br /> i; i
<br /> Josiah Milton Shultz
<br /> Et,,, e. •aehr>,jka
<br /> i Ss 7
<br /> ■
<br /> December 55_- 3: -
<br /> 00 1•
<br /> end_i
<br /> iscel. .yam /�Lf6- = I
<br /> —v /aC J3t6 ��-r-=LD 1
<br /> Fees $-.as25-
<br /> i
<br /> r 2Ic&(-ti
<br /> f
<br />
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