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Vq 71 IV
<br />PH&-798(VS) REV. 7-63 STATE OF NEBRASKA
<br />DEPARTMENT OF PUBLIC HEALTH, DEPARTMENT OF HEALTH
<br />EDUCATION AND WELFARE Bureau of Vital Statistics
<br />BIRTH NO. 126____ CERTIFICATE OF DEATH STATE FILE NO ..... ....... . ............ . .............
<br />----
<br />(Where deceased lived. If institution. residence
<br />1. PLACE OF DEATH 'l. USUAL RESIDENCE C):. a. COUNTY a
<br />STATE b. COUNTY before admission).
<br />Buffalo
<br />Q earns b. CITY (if outside corporate limits, write Rural) C. L E N G T H OF c. CITY (If outside corporate limit., writ. RURAL)
<br />TOWN
<br />STA t8 years OR
<br />TOWN Amherst
<br />Ky
<br />d FULL NAME OF (if not in hospital or institution, give street address) (If rural, give location)
<br />d. STREET
<br />ADDRESS
<br />Z INSTITUTION HOSPITAL OR
<br />Good Samaritan osri
<br />42 0 '_ G t H ta
<br />3. NAME OF a. (First) b. (Middle) c. (Last) :4. DATE (Month) (Day) (Year)
<br />A DOTE
<br />lo-
<br />Print) Aman. Ja Berthii Siebke DEATH
<br />(_I __- ---- - -----
<br />Type or
<br />I MARRIED, I ms. If Under I Yr.
<br />COLOR or RACE 7. MARRIED, NEVER 8. DATE OF BIRTH 9. last ( n 3 If Under 24 H-
<br />0 OWED, D�VORCED (Specify) astothday) 1) M.
<br />ys I Hours I in.
<br />White 11-17-'1866
<br />Female
<br />0 ioa. USUAL OCCUPATION (Give, kind of work 10b KIND OF BUSINESS 11. BIRTH - (City, town or county) (State 12. CITIZEN OF WHAT lu
<br />'< even if retired) l OR INDUSTRY PLACE or foreign country) COUNTRY?
<br />done
<br />moat working life,
<br />fe Own ome MayVil e, Wisconsin U. S. A.
<br />13. FATHER'S NAME 14.. MOTHER'S MAIDEN NAME HUSBAND OR WIFE
<br />0' Fred Schukar Marie Sasse oke �Deceased)
<br />Address
<br />15. WAS DECEASED EVER IN U. S. ARMED FORCES? � 16. SOCIAL SECURITY 1 17. INFORMANT'S NAME or Signature &
<br />St (yes. no, or unknown! (If yes, give war or dates of service) 1 NO
<br />0.0 1 None Mrs,-Edna Hermann, i�mherst Nebr.
<br />- -z No -4
<br />0 Ez Ei
<br />MEDICAL CERTIFICATION Interval Between
<br />4 11, CAUSE OF DEATH J
<br />z Enter only one cause Pe: I. DISEASE OR CONDITION Oruiet and Death 1�,.
<br />line for (a), (b), and (c) DIRECTLY LEADING TO DEATH*
<br />bro cho Dnewrionia
<br />..... ....... P .............. I ................................ ......................... .................... . .... ... ..
<br />-This does not mean the ANTECEDENT CAUSES ilrteriel Ne-nhro,�clerosis
<br />as mode of dying, such as DUE TO (b) ................................ .. -I .... ......... .................... ...
<br />4,.4. 41
<br />z CW!5 1 heart failure, asthenia, Morbid conditions, if any, giving
<br />W.% �1 etc. It means the dis rise to the above cause (a) stating
<br />2100-. 1', ease, Injury, or .complica- the underlying cause last. DUE TO other Sclerosis
<br />................. ...................... ................. ...... .................... . ................... ............
<br />I lion which can ed death.
<br />_3 II. OTHER SIGNIFICANT CONDITIONS C stitl.s
<br />Conditions contributing to the death but not
<br />as o�W related to the disease or condition _causing - death,
<br />0- 719.. DATE OF OPERA- 19b. MAJOR FINDINGS OF OPERATION 20. AUTOPSY?
<br />TION
<br />YcYX No _E]
<br />-.3 1 21a. ACCIDENT (Specify) 21b. PLACE OF INJURY (e.g., in or about SUICIDE i "ic. (CITY OR TOWN) (COUNTY) (STATE)
<br />> .0 ihome, farm, factory, street, office bldg., etc.) (If rural area, write RURAL)
<br />HOMICIDE
<br />21d TIME (Month) (Day) (Year) (Hour) ne. INJURY OCCURRED 21f. HOW DID INJURY OCCUR?
<br />o OF
<br />While at Work El
<br />-
<br />INJURY in.� Not While at Work E]
<br />22. 1 hereby certify that I attenq 0 t
<br />.77A . - 5k
<br />r V ed the deceased from ... i 0AI.. 19-54., to-.1... 3-- 19'. that I last saw the de- �-J
<br />ceased alive on .... IQM2� 195.4..., and that death occurred a&.1.00T..m., from the causes and on the date stated above.
<br />x
<br />(Degree or title) 23c. DATE SIGNET)
<br />23b. ADDRESS
<br />23a. SIGNATURE
<br />M. D__1 Kearney, 1). JD1 y, Nebraska 110 -25. -54 (State) soll 24c. NAME OF CEMETERY OR CREMATORY 24d. LOCATION (city, town, or county) (S
<br />24a. BURIAL 4b. DATE
<br />CREMATION ❑ 10-27-54 1 Immanuel Cemetery lunherst, Nebraska
<br />,a REMOVAL LI(Specify)l
<br />FUNERAL
<br />DATE RE BY LOCAL, REGISTRAR'S SIGNATURE
<br />E- 5 1 __ _L_ __ ;_ - - - 1 DIRECTOR'S SIGNATURE ADDRESS
<br />l� 10-27-54 REG.i rriette J. Nelson RoLlt L. Johnson earneir Nebraska
<br />Hal K
<br />County of Ruffzlq ----- Iss
<br />State of Nebraska J
<br />On this ....... . 27t11 ----- day of --- ..Cctober --------- --- _ 19_54_
<br />Johnson -------- -------- -- - .. ------- ------ a Notary Public duly appointed, commissioned and qualified
<br />..........
<br />f6i % 'Clad 4ftn f4,jipid county hereby certifies that the above is a true and exact copy of the Certificate of Death
<br />0
<br />been filed with the Registrar.
<br />. .................which has be ...
<br />Vi X
<br />and seal the date last above written.
<br />A
<br />-----------------------------
<br />--- --- -------- ------------- ----- ----------- -
<br />""T ied for record NOV.12y 1954, at 2:45 R"t B�f Ppeds
<br />
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