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4z�--"— <br />J <br />..rill Yen <br />STATE OF NEBRASKA <br />' <br />r(ACE (IF DEATH Bureau of Health - Division of Vital Statistics <br />DO "Ot write .. tm. xnacq <br />county ?`- `=at8�'--- _... - -- CERTIFICATE OF DEATH <br />A _I <br />'" <br />'1'ewnnh,p <br />'• <br />0 <br />If death occurrod to s hoepItal <br />Iln NAMF. <br />« <br />L`. _— <br />l' ILY... !a�Q ........................... No..... 19(y��, RVBOt.JO.•�t' <br />or Institution Rlve <br />...... ............ Instead of stre0t and number. <br />e <br />'y <br />I.rngth of re.xido -o In city or town where death occurred10yr..... <br />m"....Ja. How long In U.S. If of foreign birth.... yr..... mo.....da. <br />2. FULL NAIlIIpE . OW iii. At,. aQ♦ QW♦IBa ....... :......... ....... <br />... ................................................................... <br />iY0�..1tQ. •.. t'.h T .. I.... .. <br />... ............ ............................... .... <br />.G <br />,ce .!I ...... ............ <br />— _ <br />PER80NAL AND STATISTICAL PA TICV LARB <br />Writ. the <br />MEDICAL GE IFIGATE OF DEATH � <br />�� <br />ed <br />{ l,U I2 �("E <br />I �1'ite <br />word) <br />S_Divro° <br />LI' DATE OF DEATH <br />I�! <br />G <br />.ac.le <br />It - 1, wldowstl oc divorced <br />�d <br />ied <br />� I MER BV CERTIFY, hat ttondod asaea f <br />•' <br />u <br />I1USI3AND f <br />fl ...... <br />a <br />u <br />tt> 13't.{t�P9tSm%1 RU _. _. - -- - <br />`[y <br />I last sew )ar.».N nllve on. ". .. /,�J...., 1 U said <br />" <br />fi. 1LnTF. OF ISIRTH (Ino.) �^Iiie (dnY) UJ (yr.) 8Q7 <br />-�_ <br />/ydeath <br />l have ...... ca rae ohs date atnl'J abovo, at... QY M. <br />as <br />Phr principal u f d th and elated Causes of Impor n In <br />- _ <br />Age Years Months I)aYC if 1 li I 1 day <br />order of onset were as [ullows: <br />jj <br />7. <br />U of ..nest <br />i <br />kind of we' ti <br />.. ._......... <br />� <br />q <br />E1-j <br />I'^ <br />o <br />- bookkeeper. etc <br />! <br />:,. mdoelrY or bnemeas m which <br />work w'as done, an silk mill. <br />-... <br />........ ........... . ....__... <br />_ ......... _. <br />i <br />a <br />, <br />aaw mill, bank, etc ............................. ...... <br />.. .. .. ........... _ <br />............ ... <br />G <br />V <br />10. Date deceeseJ lna[ worked [ 11. Total time ( Years <br />this occupation ( ..nth and eDent in [hie )_. <br />......... � <br />.. _ ................ <br />rt <br />i a <br />rear) .... occ 1 cl .. <br />_— -- <br />Do iI o <br />la. stash Iace cur o t � <br />p d <br />lb t ry cauaea f 1 rice [ ed to Drinclyml csuee: <br />J .-........... <br />o <br />State an_ <br />t y Diioh-6_ -- <br />-- - — <br />..._ ........ <br />{ <br />_ <br />° <br />1:,. Name of Felber Edward Cowles <br />_.......... <br />........... _ .......................... _...................... <br />A. <br />17. Birthplace J City or town ..... ............................... <br />Name of operation... .......................... Date of............ <br />. v <br />Fathet Etat oidcountry_ ORSO_ _.. -__ <br />55'nnt trst .... firmed dlnRnnsls ?......... Wna there an autoPeY ?.... <br />IS. Malden name of Mother O1.9a- ---- <br />.n. If dralh was due to external cause (wlele"ee) fill in also the <br />` <br />F •, <br />" <br />-- - - - - -- <br />;.. Slcthp4ce City or town....... .......................... <br />following: <br />AcclJenl. suluiJe, or homicide'....... Onto of Injury .......; 19.... <br />' <br />uw <br />....� <br />O1 k'd <br />Tforhrr QB <br />Whore did Injury occur? .............. ........... <br />I <br />cl <br />Stnta or ..try I7[IORt <br />- __ <br />(SPeciry city or town. county. and fltntel <br />:pedfy whether injury occured In Industry, in home,or In public place <br />'~ <br />11. INFORMANT .....•'.•rS.•. <br />Shlmer of mn, ry .................... ......................:........ .. <br />roU <br />13. HURIA(.URI , CI :- ;. "vt`: "N C,+ ;i . \7!nt'. \L <br />N::turr , f Injury ...................... ............................... <br />P <br />wee disease or Injury In any we, related to occupation of <br />. W <br />1 11 UNDTAI : -. 1 . ilP r ......... <br />If so dD fy d�... .... <br />.. . <br />(_All )' <br />'.. <br />- "'�"'� <br />r: gwl,lli0 T <br />d Lr.... .. \I. <br />i. <br />�I,e , ,., trr t J Itiyvu dj Registrar. <br />IAlo-caq /.� frik�rl'ua. -�... .. <br />4z�--"— <br />J <br />