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<br /> 14E1 Oil 4.4,1'-',114 PUBLI, 11,1,711 DEPARTMENT OF HEALTH
<br /> ,n 4 S:IoN AND Vi LISNRE
<br /> Bureau of Vital StatIv11.,
<br /> VOtill No 126 • CERTIFICATE OF DEATH ,sr,. 14.1 1. No
<br /> , I 141.1t E 11F DEATH
<br /> 4 a •4 it NI l' • ig.f.g4-admissiont. 1
<br /> b CITY If (sate Nimsgate limas.write Iturali 0.T t ('N G T It OF g 1 11 l' If outs M.enrIvorate lungs,wrgt RURAL)
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<br /> ( TiliN : .
<br /> 41 FILL NAME OF III not In hoshltal or instituN» gls. street J.STREET III rural.ithe location)
<br /> 'j. riTITTW1Ig'' address) ANA:Eh, 4
<br /> s
<br /> I a NAME OF ...Ian.) S.tatiddl, e 11.0,» 4 CITE (Month) WRY) (Year)
<br /> DEI ENSED
<br /> \ , ITylw(lc rt.'. - 14EATH 5 20 55
<br /> ,
<br /> \., ,SEX I COLOR or RACES riR,F,MLI,16.Ni=14.,3irRsl.E.,,,Ii.b.,44 liAlE OF BIRTH 2 I.A..4,1FEilir14,4,dwittm.1Zder,!,.X.r.It_1.1.,unl:r 2.1 1,I,rs,
<br /> "—
<br /> .—_- „•. _-- ) 10 2" '
<br /> ■ !,•,,,,' !;i1,15,,t.m2t(iT,E.:1;112,:izi,.,,r'I orSki I, RIND,f,1K INDUSTRY PLACE II I11,14.7.11 It Ity.town or((county) (State II,t!MEN OF WHAT ,
<br /> or tos-stsen"mot,/ COUNTRY'.
<br /> ,L!\■ IX FATHER'S NAME 141.MOTHER S MAIDEN NAME 14h NAME OF HUSBAND OR WIFE
<br /> t.,;4 ' IS.ATAS-Isi-CE.ASED EWER IN U.S ARMED FORCES(' 16.SOCIAL SECURITY 17 INFOltSIANTlS NAME or Signature&Address
<br /> EA,j Ibles.no.at unknown(If ywt.gtse war or dates of eon lee) NO
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<br /> FALSE OF DEATH - -. , - - NEDICAL CERTLFKATIoN Interval Between
<br /> 1: , N,,ne.`40,1"(151)..rw`..:,",7,`)I.DISEASE OR CONDIT.ION' Onset and Death
<br /> DIRECTLY LEADING TO DEATH*
<br /> A C (a)Eroncha.:4Qnic rurcincariu with 5 -or, 'i
<br /> • t . metastarec, Ichei-aiz_d
<br /> n,.. ., mo.,T.Itdez:rel n=Hz ANTECEDENT CAUSES USES
<br /> DUE TO (b) •
<br /> r,.24 1 bra. tailnrs• ast.he,7::: Morbid condition. If •ny, giving-g;\\ "1'..•1^ 7;4..7. 'IF's.- 1.147 alde'r;y1t7atf:e"ras(..).'""DUE, TO te) to
<br /> , Hon which causeAd eat&_ ._ _
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<br /> II.OTHER SIGNIFICANT CONDITIONS
<br /> Conditions contributing to the death Not not
<br /> ‘
<br /> related to the di%%%%%or condition causing death. .
<br /> 25, \Z
<br /> DATE OF OPERA 19h MAJOR FINDINGS OF OPERATION
<br /> .0.A(Oivzsv,
<br /> MN ' Yest NOD
<br /> 3 42I....AIJCLIJEUT- +Streit.) -,41144.-PI-AGE OF INJURY SET in-or-about.-Me.K.IT.Oit T-OWN)- - -(640UNTWA - - MiThATES)-
<br /> . E SUICIDE home,farm,tact.,lit,,,).office bldg.,etc.) 1If rural arra.wytte RURAL)
<br /> . a HOMICIDE
<br /> 21.d.lily. _al.r.). ..(Yurl_ lifour)...%,I.ratickCYRVI:w..lio3y 1.ao_1uutri J.K.C.J.IL? .
<br /> . INJURY tn. Nos While at Work 0
<br /> .3.
<br /> • S. 01.1 hereby certify thatA attended the deceased front.5..3.. 19...5.,to..5...20 ,19;3:,Iliarrla/LtZsdioLISha ;
<br /> that death accursed at 111.55•044rom the causes and on the date stated above.
<br /> ,It' II..SIGNS y' - (Degree or title) 23h.ADDRESS 2244.DATE SIGNED
<br /> .Ltb 4-1
<br />• i E a •j ' 1() ,."I' ,-.,, .n^ .I.,.',__,.. , -,_- 5-2155 '
<br /> ,4 ,M.BURIAI. 1 r''-21V3.D TB'' I 24g.NAME OF CEMETERY'tlitCREMAitARY I 24d.LOCATION (Cit..144'.4.0.or smutty) (State)
<br /> t,4 I. CREMATION Ei ,„) Ma 3/58 . II ci 1 b
<br /> : t,DATREE.MmOV.,ALi fails W .:,. .an_ sm• al Par. . rand eland, e r.
<br /> 1. CAle-r-1:21,y SON.467 • .FuNE.•L E'TOWS SI' .TURE &DIMES/
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<br /> ' • - - -41101.1111■- . .' _ - -'''' . ,
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<br /> -TE-tiTS"CERTIFIEB THE ABOVE TO BE A TRUE COPY OF AN ORIGINAL
<br /> "CERTIFICATE 0q.,_-1LE WITH THE STATE DEPARTMENT OF HEALTH.
<br /> -BNI t.1
<br /> N:A -OF $1:1A1, STATISTICS, WHICH IS THE LEGAL DEPOSITORY ,
<br /> FoX,NrkTAL,-1-z.Et o R D s.
<br /> _ DIRECTOR OF ITAL S ATI TICS AND ASSISTANT STATE REGISTRAR ,
<br /> LINCOLN, NEBRASKA — 1955 ._
<br /> Issued June 2,
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<br /> state of Nebraska
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<br /> CLun'...y of i fan
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<br /> itered o Huiner;cal Index and filed
<br /> for ;ei.'ord :r.: C!-I-k:._, 0'.. ,R,.....0St er of
<br /> L,-,,I. -J.:: Li...? 9 .__ :-..tely of
<br /> February . 1.9 56 _ zst . 2
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<br /> Fees $ 2.2 pd• Pt 5Y
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