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STATE Or NEBRASKA <br />DEPARTMENT OF HEALTH <br />Dlvlli of VIte[ 6btlsda <br />STANDARD CERTIFICATE OF DEATH <br />DEPARTMENT OF COMMERCE 6)tn lr <br />BUREAU OF THE CENSUS Soclal Srcorll> No..... St to FII No... , 1,�- .. .... <br />_ — <br />I. PLACE 01' DE�T - - 2- -USUAL ItE/'J�II EN(.E Uf DE(t �SkD n <br />.,( ..... la) State fl. A•l /� .. ( %b) Cou�ttf.. q/ <br />ln) Count <br />(b) CItY or town ... °/� fl <br />I outnldo clef Its RURAL) (c) CIIY or to n.. - (if outelda ctt> ar tbw Ilmlte, wrl4 RURAL) <br />Ic) N frM1/ Dltal I tl tlon <br />T ... .. .._ ....'If oral W... lo ..c a ion ) .... <br />.... ... .. n ba <br />' (If t l D tnl I tit 1"'" Its t z <br />Td) LenR[h nt etn9 9n hosDltel or institution .. M�'k -- (c) if t I bore. how long In U S. A.? .... <br />MEDICAL CERTIFICATION <br />_ 19p —cclfy hreh Y _.__ ],x .._...19.1d <br />- ........ 20. D m t d h. Month !df'NSL {t d' Y . <br />/c tif, hour .. m t M <br />fn) till 1 NAME t. Lh b fY that I m ded tho dernneed flato <br />ar... _ ... .. ... ..... <br />that I ].at h-CA...-Ill on <br />.,.- 1.:.... lA. <br />— 6. Col 8( ) 31nH1 id oJ, m Ied <br />) and that death Deco 1 tho`,dnm d b rtattd bo II tl <br />d SoY�f 'f.i'I rc, !h _:_Y I d,vo e«1'+% Immnli t t d th.. . Jn <br />Ax <br />Olb) Nam' of hudw d ifo a() ARC of hu.hnnd or ... <br />wife it sllva. > LL <br />Bi dam -f da of de f I.. plr W .......t 3 .. L Y. <br />_ (Month) <br />ACE Yenra Month. ')-Y- i­ oY. I If I than 'nn day ....... .... .. ... <br />: ... .. - <br />u H <br />H. BirthDixce...... i ✓..!L.M.......ct.u...ri_....... -e Stnte'r l <br />(City, tow o eouvty) <br />Usual ocruDe'ion <br />11. Industry or bus . <br />E I <br />I2. Name.. <br />I � <br />fi I <br />I 1J Maiden nn .. ^'t'h K <br />T I <br />I R( (CUY, town. o ty) (b t <br />'a I <br />II ]H. (n) Informant'. own .IRnntDrc . Y <br />(b) Add ,.. D m the ht.f <br />l)(b) e <br />L tZ <br />( <br />1 b <br />.... ....... ... ........ <br />—' Other mndi [love .......................... <br />within a - <br />Y � ([ncludo DreRDavc> month. of death) PHYSICIAN <br />Major BnAinR;t u d mna <br />_... _. Of o raann.. .. . _.. ehio... t wch l <br />hnd o <br />ba <br />pay Of L o i Ra.a <br />ai ranr. <br />i d Ntl if drath w.m dae to 1111 rnnl rauzo. fill in th,• follooi— <br />l.Y) (a) Accident, suirtd h I 1 1 f ).. ...... ... .... <br />Y¢�' -. (b) Dam of occorr .. ._. -.. ............ . <br />Ic) Where did injury orcur t. (GItY or mwn) (County) lVlnml <br />on term, In industrial Dlecc, in <br />(dl Did fnjur, oc 1 nhnut h I <br />public Dlncet -. ........ ... .. <br />ism if YDD f DI ) <br />�r W611 at work () Means f injury.... <br />r <br />v� r othor) <br />J Za. S ¢n tore R f .... �)' <br />D l Rned $ -3L <br />5i turcl Addrea..... - <br />- �� rt.•Y -fON �., <br />