Laserfiche WebLink
I' <br />ail PRS- tDe1V9) $TATS OF NEBRggRA ' <br />DEPARTMENT OF PUBLIC HEALTH, <br />EDUCATION AND WELFARE DEPARTMENT OF HEALTH <br />i' Bureau of Vlt.I gtatr[tica <br />E� BIRTH No. 126........ CERTIFICATE OF DEATH STATE FILE xo...._. <br />�y 1. PWCB OF DEATH -- 2 —USUAL �EE331)D <br />'! a. COUNTY .. STATE N li LE (Wh °d .ee Ifv.dlr 1 ue it <br />c !. ¢ b COUNTY tier Wmt 1 ) <br />b. CITY (If oatnlde r.4 Ilml rite ur.Hic. LENGTH OF ? - - #,,I <br />TOWN�•.L•• 9TAY e. CITOYR (If tilde W b Iimltn rile RU/R�AL�) /- <br />Lr 11 TOWN <br />A. FULL NAYS OF (If not to hoepit.l or i tit t1 <br />xdl l l IH ddr[e.el t I d lREEOSPITAL OOR RkT, NSTIT.TI y L,LS All) lir r I, [Ive bevllon) <br />- -.- <br />Y D. NAYS <br />1 ECEASED , t' (L..11 -- -- i - -- -' _ - -- <br />S 1. DATE o th) ( /Y) IY -- <br />-lTrr' Ll��IIM D. NEVR FAT1 I blrthd ) M 5. 9E% 8. COLOR or RARRIED NEVER MARRIED 8 DATE OF BIRTH D AGE y If U der1 Y JI 21ryDOWSD DIVORCED (9 if ) <br />' <br />1.11 . USUAL OCCUPATION (Give kind of work tl pb, EINp OF BUSINESS( II. BIRTH- City, to - �l L — <br />d nod 1 y qt of workin. III ,open It,ratIrW) OR INDUSTRY ; ,R`CE or ea tr) (54te�12. CITIZEN OF�WHAT <br />�LId2L_ -OOli r Irn co ntrr <br />COUNTR0 <br />Y 13. FATHER'S NAPE EA'S MAIDEN NAME YF[I.'. �%��.� - - -�� <br />116. NAME OF IIUSBAND OR WIFE <br />1)OMNS� 4Qq/NO EE /t Abe f� �Nd✓ ' <br />k' $ <br />i a p I(hY� eaWAS <br />o� . 2 DoEr CuEnAknS—oEwD nL E y R I a e S AR Eja FDORCES} )' J 1 6O . SOCIAL Z SEC/UQRtIr TY <br />i �J7. , S lJ.— a . <br />lvum • va s Add— <br />Z <br />111 CAD 36 OF DEATH( - <br />q: l I e i lyl Ill a.e pet MEDICAL CERTIFICATION - <br />nd (c)I 1. DISEASE OR CONDITION <br />R <br />DIECTLY LEADING TO DEATH- <br />' O t .nA eDt.t6 <br />m 'Thl d of .. fill <br />e[n thel ANTECEDENT CAUSES <br />3 mea. ar drin[, .arh .. causing <br />G�' bout (.Ilan, DUE TO (b).._.. <br />m.�a 1►v dl M hid rondlllone, If [I i [ " " -- <br />1 <br />UOE w, (Nan. er a+mvll h Berl >In[ evaw Wt. <br />I lbn whleh evueed d DUE TO (e) <br />< Q 1I OTHER SIGNIFICANT CONDITIONS <br />ro CI died t h di ihutin[ t th I.— b <br />- ___ -__ ev o rondltlon e.veln[ de.th. <br />FO. 10a. LATE OF U `ERA �I86 MAJOR FINDIN <br />TION GS OF OPERATION <br />8 - - <br />2d. AUTOPSY! <br />�. <br />21a. ACCIDENT (Sperlfy) 216, PLACE OF INJURY (e.. 1 bout 1 (CITY OR- - 1 <br />Yee Nom <br />SUICIDE home, f. fa tD t t If bld tc.) IIf (COUNTY) (STATE) - - <br />e HODIICIDE <br />to RVRA ) <br />21d. TI FE (Month) (D.1) lyevr) (Hour) 21 INJURY OCCURRED - <br />./ !If. HOW OIU INJURY <br />g IINJURY NWhi tW k (4L hereby certify that I ditom _ "-aa O'ee�� `t"L.Gr- - �•Y.cpaty,wJ - -- - - -- <br />eeaaed alloe on • (I 19SIItt ,and that death occulted ¢t PkaOPm , taaf oats the de- <br />j'= F - _.. _ Jrom the causes and on the date stated above. <br />128x. SICNATVR (I4.ree or title) ) 2Jb. ADD ESS - <br />8 <br />L(�3���1J�W �.•v�a' 2& DATE SIGNED <br />21.. BURIA AT 7 C :E 24c. NAME OP'- CEMLT�ERY Oil t,RE A'(ORY 2�d. LOCtvty_tua_ <br />MAT.MOVADATF. RRC•D RY '4� 'R' U <br />w[•w • r 1nrK'G' II _ <br />Issued Octiber 1, 1954 <br />7 <br />