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Y <br />r� <br />a <br />W CQ <br />�+ O c <br />z <br />b S <br />0 <br />aw w <br />� a <br />d <br />W <br />a <br />ea v <br />y •Zb <br />E <br />z vx� <br />FM A <br />b�3v <br />A <br />N ��b <br />a� <br />• �d$ t <br />° cam <br />>" A Y <br />W m <br />4 <br />of w <br />r � P <br />y P <br />G • <br />E � a, <br />kv <br />m o <br />�o <br />v <br />" v a <br />Fa s <br />0 <br />a� <br />H � <br />A <br />WHO I <br />H x <br />UH W <br />w O' <br />W. <br />i-1 <br />Cd <br />CU <br />A <br />DEPARTMENT EOF PUBLIC HEALTH, STATE OF NEBRASKA 7VmV. <br />EDUCATION AND WELFARE DEPARTMENT OF HEALTH Bureau of Vital Statistics Vd&"�' <br />o,nmzr 199 CERTIFICATE OF DEATH RTATP FTT,P.. Nn. <br />1. PLACE OF DEATH <br />2. USUAL RESIDENCE (Where deceased lived. If institution: residence <br />a. COUNTY Alll <br />a. STATENebrAt3ki7�, b. COUNTY 1 ll�fore admission). <br />b. CITY (If outside corporate limits, write Rural) <br />N G T H OF <br />(If outside corporate limits, write RURAL) <br />c. CITY (If <br />OR <br />STAY <br />TonGrand Island- <br />TOWN <br />d. FULL NAME OF (If not in hospital or institution, give street <br />d. STREET (If rural, give location) . <br />HOSPITAL OR address) <br />ADDRESS <br />INSTITUTION <br />3. NAME OF a. (First) b. (Middle) c. (Last) 4. DATE (Month) (Day) (Year) <br />DECEASED '�t DEATH A r 3 955 <br />Clara Mae <br />Type. or Print) -Carlyle___ - -_ <br />5. SEX 6. COLOR or RACE 7. MARRIED, NEVER MARRIED, S. DATE OF BIRTH 9. AGE (In yrs. If Under 1 Yr. if Under 24 His. <br />IVORCED (Specify) last4b't,�rthday) Mos. 24 Hours Min. <br />Female White 19arried j 1 29 1..905 <br />10a. USUAL OCCUPATION (Give kind of work <br />10b. KIND OF BUSINESS 11. BIRTH- (City, town or county) (State <br />12. CITIZEN OF WHAT <br />d�o a dgyng most of working life, even if retired) <br />OR INDUSTRY PLACE or foreign country) <br />COUNTRY? <br />A Ii0II1@ <br />W <br />13. FATHER'S NAME <br />14a. MOTHER'S MAIDEN NAME <br />14b. NAME OF HUSBAND OR WIFE <br />Frank J. Caul la <br />16. WAS DECEASED EVER IN U. S. ARMED FORCES? 16. SOCIA SECURITY 17. INFORMANT'S NAME or Signature <br />& Address <br />(Yes, no, or unknown (If yes, give war or dates of service) ,rankj,:;04,; le -drw <br />f�.' it Lao <br />18. CAUSE OF DEATH MEDICAL CERTIFICATION -�� <br />Interval Between . <br />Onset and Death <br />Enter only one cause Pex I. DISEASE OR CONDITION <br />sine for (a), (b), and (c) DIRECTLY LEADING TO DEATH' <br />aas....Gs Gangrene <br />3.0.0 <br />(a) ........... ..................................................... <br />............................... <br />*This does not mean the ANTECEDENT CAUSES rul t 1 le le r© i <br />TO b)...........± 1 p.............. �i......................._........ <br />mode of dying, such as DUE ( ................. ...........m�..a............... <br />heart failure, asthenia, Morbid conditions, if any, giving <br />etc. It means the di- rise to the above cause (a) stating <br />ease, inJury, or complica- the underlying cause last. DUE TO (c) .......................... <br />tion which caused death. <br />H. OTHER SIGNIFICANT CONDITIONS <br />Conditions contributing to the death but not <br />related to the disease or condition causing death. <br />1 19a. DATE OF OPERA- <br />19b. MAJOR FINDINGS OF OPERATION <br />20. AUTOPSY? <br />1 TION <br />Yea � N� <br />21a. ACCIDENT (Specify) <br />21b. PLACE URY (e.g., in or about <br />21c. (CITY OR TOWN:) (COUNTY) (STATE) <br />write RURAL) <br />SUICIDE <br />home, farm, reet, off ice bldg., etc.) <br />�factory, <br />(If rural area, <br />HOMICIDE <br />TIOME (Month) (Day) (Year) (Hour) <br />21e. INJURY OCCURRED <br />21f. HOW DID INJURY OCCUR? <br />21d. <br />While at Work El <br />INJURY m. <br />Not While at Work ❑ <br />1 .r 23...... 19 .... 5�that I last saw the de- <br />I the deceased /rom.�aA..- ......, �9- 5....., trip ... , <br />1 zz.I hereby certify that �ayttended <br />ceased alive oA_pr..a `2y 19..55, and that death occurred at3,25M from the causes and on the date stated above. <br />23a. SIGNATURE (Degree or title) 23b. AD DRESS 23c. DATE SIGNED <br />I2 <br />24a. BURIAL 24b. DAT 24c. NAME OF CEMETERY OR Y OCATION (City, town, or county (State) <br />e CREMATION A r.26 5 Phillips Demeter liebr <br />p / i� y Phillips, <br />REMOVAL <br />DATE RECD BY REGISTRAR'S SIGNATURE NER L CTOR'S SIGNAT <br />4LOCAL <br />Apr. 26/58. White <br />t-M•1 <br />U <br />Cd <br />U� <br />KS i <br />�v 'itt } �➢� <br />tea 5 M <br />p 1 <br />