|
PHS-798(VS)REV.7-68
<br /> •
<br /> Cif r i•
<br /> y DEPARTMENT OF PUBLIC HEALTH, STATE OF NEBRASKA �� / •
<br /> T. 11i EDUCATION AND WELFARE DEPARTMENT OF HEALTH !A '� `r j
<br /> Bureau of Vital statist, t'■V n H. e d 'e s
<br /> BIRTH NO. 126 CERTIFICATE OF DEATH STATE FILE NO
<br /> I. PLACE OF DEATH 2. USUAL RESIDENCE (Where deceased lived. If institution: residence
<br /> . pi a. COUNTY - a. STATE b. COUNTY- efore admission).
<br /> Hall Nebr 'Mall
<br /> t so
<br /> ql b. CITY (If outside corporate limits,write Rural).:e. L E N G T H OF c. CITY (If outside corporate limits, write RURAL)
<br /> g TOWN Grand Island. (STAY 30 rs. To°wNGrand Island.
<br /> d. FULL NAME OF (If not in hospital or Institution. give street d. STREET (If rural, give location)
<br /> z INHOSPITAL OR St Francis Hoseital address) ADDRF.9 49 2323 )lest Lincoln HIM
<br /> l'.3 B S 8 DECEASED a. (First) b. (Middle) c. (Last) 4. DATE (Month) (Day) (Year)
<br /> aOF
<br /> j. or Print) V all le C Koch DEATH Jan 28.1956
<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 /> D4 a o dj Male White [ dDIVORCED (Specify) Feb. 4 189 1as61u`Jrthdar) M° Days Hours Min.
<br /> w
<br /> 14 m i
<br /> .4 1 ( 10a. USUAL OCCUPATION (Give kind of work1l0b. KIND OF BUSINESS 11. BIRTH- (City, town or county) (State 12. CITIZEN OF WHAT
<br /> , done during most of working life,even if retired) OR INDUSTRY PLACE or foreign country) O NTRY?
<br /> w $ • : . _ . _ - • aro, 41e`tDr. USA
<br /> v
<br /> m 14a. MOTHER'S MAIDEN AME 14b. NAME OF HUSBAND OR WIFE
<br /> 24g Anna Hood Effie Koch.
<br /> w O$ ea
<br /> 16. WAS DECEASED EVER IN U. S. ARMED FORCES? 16. SOCIAL SECURITY 17. INFORMANT'S NAME or Signature & Address
<br /> o pii a (Yes, no, or unknown!(If yes, give war or dates of service), NO.
<br /> I emmli: • . . Effie Koch Grand Island_
<br /> Plo '°ea a 18. CAUSE OF DEATH MEDICAL CERTIFICATION % • •JIntervai Between
<br /> iv, .;S a Enter only one cause pet !Onset and Death
<br /> •
<br /> g"" P•e3 line for (a), (b), and (c) I. DIRECTLY LEADING TO DEATH* •
<br /> 1701 (a) Carcinoma of Bladder lyr
<br /> .. ole 4
<br /> gs° •TbIa does not mean the ANTECEDENT CAUSES
<br /> a+ o mode of dying, such as DUE TO (b)
<br /> °= heart failure, asthenia, Morbid conditions, if any, giving
<br /> 7...40.f.,°� etc. It means the di,- rise to the above cause (a) stating
<br /> @'ep a ease,Won'. or tompllea- the underlying cause last. DUE TO (c)
<br /> Q w..0 tion which caused death.
<br /> a et s' II. OTHER SIGNIFICANT CONDITIONS
<br /> 17 Conditions contributing to the death but not
<br /> fts o ems related to the disease or condition causing death.
<br /> 4 6 O�• 19a. DATE OF OPERA- 19b. MAJOR FINDINGS OF OPERATION 20. AUTOPSY?
<br /> $>F TION
<br /> c3 6 Yes 0 No
<br /> y W,; Q 21a. ACCIDENT (Specify) 216. PLACE OF INJURY (e.g., In or about 21c. (CITY OR TOWN) (COUNTY) (STATE)
<br /> G . HOMISUICIDE
<br /> DE home, farm, factory, street, office bldg., etc.) (If rural area, write RURAL)
<br /> • 'ER s .b 21d. TIME (Month) (Day) (Year) (Hour) 21e. INJURY OCCURRED 21f. HOW DID INJURY OCCUR?
<br /> El E a OF While at Work
<br /> $ INJURY m. Not While at Work fl
<br /> d o A 22.I hereby certify that I attended the deceased from 10/5,,59 to 1./.26/..i5, 9 , that I last saw the de-
<br /> o.« .-.
<br /> • 1; .t• ceased alive on 1..28 .5.6_, and that death occurred at 10,4004U the causes and on the date stated above.
<br /> ax ti 28a. SIGNATURE (Degree or title) 236. ADDRESS 23c. DATE SIGNED
<br /> 0,.., g . ' .. 1/31 56
<br /> --
<br /> u 24a. BURIAL EX 24b. DA 24c. 4•ME OF CEMETERY OR • MA .•:4 .s Lem •ClIQ (City town-or county) (State)
<br /> :` a CREMATION 0 Jtin31. 1.56 Westlawn �l orial Grand `.s1anc�, ��e�r
<br /> ° u REMOVAL •;Specify) _ _ 4 �.
<br /> as .. • DATE REC'D BY LOCAL REGISTRAR'S SIGNATUR / •V e• 'Y..• . s /,
<br /> i -b 1 56 REG. F. S. White % ��'�� /,...0w.';.;
<br /> ! _ice �..,i/�i./-- �_
<br /> *w cji r
<br /> ..,,,,
<br /> i x It
<br /> i-h x &E.E
<br /> 'S . -
<br /> I.
<br /> 411 0
<br /> m
<br /> k.k.‘ . • re._1.` 'O fa O . �A•i ��
<br /> t iss x"a,w O,o C
<br /> �'t a
<br /> n
<br /> S a PP ii•
<br /> ....g. R.R.i P
<br /> i
<br /> t \
<br /> • i
<br /> k - t = .
<br /> •
<br /> VI s - - -
<br /> •
<br /> •
<br /> '4 a 9
<br />
|