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i ii.ze. 76, • 4 - 3.,16 _
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<br /> 1 PHS-798(VS)REV.7-65 STATE OF /'p�• -
<br /> f DEPARTMENT OF PUBLIC HEALTH; NEBRASKA 1 , ,
<br /> EDUCATION AND WELFARE DEPARTMENT OF HEALTH Y
<br /> Bureau of Vital Statistics - - : • t -: _es.
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<br /> BIRTH NO. 126 CERTIFICATE OF DEATH
<br /> STATE FILE NO.........................___ --.-.-______-
<br /> 1. PLACE OF DEATH 2. 'UAL • 'I a 51 CE (w. re lived. If institution: residence
<br /> a a. COUNTY Hall a. STATE Nebr
<br /> b. COUNT 811 before admission).
<br /> t t b. CITY (If outside corporate_Bmita,write Rural) . LEN G T H OF c. CITY (If outside corporate limits, write RURAL)Sr OR
<br /> ',- TOWN Grand I sl:nd sTA :. TOWN c I_ :.:d
<br /> d.FULL NAME OF (If not in hospital or institution, give street d. STREET (If rural, give location)
<br /> s z HOSPITAL ioN _ . . address) ADDRESS 223 East 15th St•
<br /> 1 1 3. NAME OF a. (First) b (Middle) c. (Last)
<br /> .1 a DECEASED 4. DATE (Month) (Day) (Year)
<br /> ' •a .-al � or Print) -. • , _ __ DEATITOQ•1®•1955•
<br /> s 5. SEX 6. COLOR or RACE 7. MARRIED, NEVER MARRIED, •8. DATE OF BIRTH 9.AGE(In yrs. If Under 1 Yr.If Under 24 Hrs.
<br /> iN m Male White - WIDOWED, DIVORCED (Specify) last bin
<br /> DI arr�eEi' Mar. 7•l89 ) D;os. Days Hours Min.
<br /> IOe. USUAL OCCUPATION (Give kind of work lob. KIND OF BUSINESS 11. BIRTH- Cit town or count
<br /> al done during most of working life,even if retired)
<br /> OR INDUSTRY p (City. county).State 12. CITIZENg OF WHAT
<br /> • • ii : e t' . . 1• :: • lsZ'and 91egm,ntrlieb CO s r?
<br /> . `) 19. FATHER'S NAME 14a. MOTHER'S MAIDEN NAME 14b. NAME OF HUSBAND OR WIFE
<br /> 154 l • U. Peterson Katerine Schroeder. Ella Peterson
<br /> a O.. A 16. WAS DECEASED EVER IN U. S. ARMED FORCES? 16. SOCIAL SECURITY 17. INFORMANT'S NAME or Signature & Address
<br /> '3 pa cli (Yes, no, qr, unknown(If yes, give war or dates of service) NO.
<br /> .11 CI V Ella Peterson, Grand 'slat
<br /> z m eZ1 'd 18. CAUSE OF DEATH • MEDICAL CERTIFICATION • • •Enter only-one cause Mr L DISEASE OI!CONDITION
<br /> ""t'a gall,, • line for (a), (b), and (c) Interval Between DIRECTLY EADING TO DEATH' Onset and Death
<br /> C 99l� (a) Subarachnoid hemorrhage
<br /> E iamv _ 'This does not mean the ANTECEDENT CAUSES
<br /> Od os3• mode of dying. soch a. DUE TO (b) Arts. `. .Q.(.Q�„e 'O S i e
<br /> s a•,t," etc.t Itfameana hehedi� Mse tto t enabovescause a)seating
<br /> @'°O a ease,injury, or complica- the underlying cause last g
<br /> •
<br /> Q a eV w don which caused death. DUE TO (c)
<br /> S!R II. OTHER SIGNIFICANT CONDITIONS
<br /> • w Conditions contributing to the death but not
<br /> g o g related to the disease or condition causing death.
<br /> 'F 19a. DATE OF OPERA- 19b. MAJOR FINDINGS OF OPERATION
<br /> TION 20. AUTOPSY
<br /> • �° 5
<br /> Yes El No
<br /> 4 ,g 21a. ACCIDENT (Specify) 21b. PLACE OF INJURY (e.g., in or about 21c. (CITY OR TOWN
<br /> w SUICIDE MI DE home, farm, factory, street, office bldg., etc.) ) (STATE)
<br /> L. (If rural area, write RURAL)UNTY
<br /> 'y$ 21d. TIME (Month) (Day) (Year) (Hour) 21e. INJURY OCCURRED 21f. HOW DID INJURY OCCUR?
<br /> �
<br /> ,6 a OF While at Work
<br /> ,,9 $ INJURY m. . Not While at Work❑
<br /> g o & 22.I hereby certify that I attended the deceased from 19 , to
<br /> a: , 19 , that I last saw the de-
<br /> i i ,, ceased alive on , 19 ,and that death occurred at m.,from the causes and on the date stated above.
<br /> 1 28a. SIGNATURE (Degree or title) 23b. ADDRESS 23c. DATE SIGNED
<br /> K.F. Mc Dermott MD. Grand Island Nebr Nov.11
<br /> a 24a. BURIAL C. 24b. DATE 24c. NAME OF CEMETERY OR CREMATORY 24d. LOCATION (City,town,or county) (State
<br /> d d i CREMATIOP` ❑ n1
<br /> F 5 a 8 REMOVAL (Spat s V•12 55 �t rand I I. • , Gran" Island Nbbr
<br /> m .. DATE REC'D BY LOCAL REGISTRAR'S SIGNATURE s'' s •,:�rs-arr,�,% J
<br /> 12 55 REG. .r y" -1:��•'�"
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