Laserfiche WebLink
qW <br />Pxs 7sa(v's) REV. -6a STATE OF NEBRASKA <br />DEPARTMENT OF PUBLIC HEALTH, <br />EDUCATION AND WELFARE DEPARTMENT OF HEALTH le ed' <br />j Bureau ofrVital Statistics 8 <br />BIRTH No. 126________ i CERTIFICATE OF DEATH STATE FILE No.... <br />__... <br />- -- -- - - -- -- - - -_ <br />I 1. PLACE OF DEATH '. 2. USUAL RESIDENCE (Where deceased lived. on; <br />a. residence <br />a a. COUNTY 'a. STATE Nebr. b. COUNTY Hal lefore admission). <br />Hall i <br />b. CIO (If outside corporate limits, write Rural) c. L E N G T H OF I c. CITY (If outside corporate limits, write RURAL) <br />w C0 I ToW Grand"Island; -T ! TOWN Grand Island. <br />- <br />H' d. FULL NAME OF (If not in give street d. STREET - -- <br />x y .io�pital or institution, (If rural, give location) <br />a zo NS TUTIONkirst "ationa.l "ank B'i`de : ^.)DRESS 1020 West 12th St. <br />m`------------...._------------ <br />3 DECEASED a. (First) b. (Middle) c. (Lest) (Month) Da ) <br />4. DATE ) ( Y) (Year OF <br />.o a Type or Print) Mira Iflable Finch nFATHFeb. _15. 195' <br />r 5. SEX 6. COLOR or RACE 7. MARRIED, NEVER MARRIED, 1 8. DATE OF BIRTH 9 AGE (In yrs If Under i Yr. Ilf Under 4 Hrs. <br />DOWED, DIVORCED (Specify). last birthday) Mos. Days Hours <br />Min. <br />a W a emale °i White �a.rried Mar. 4. � <br />- -_- (City. ) (State <br />At dome iougeleiPe CI 18 39 <br />lOs. USUAL OCCUPATION Give kind of work lOb. KIND OF BUSINESS I1. BIRTH � Cit town or count <br />_. CITIZEN OF WHAT <br />C t of working life, even if retired �� OR INDUSTRY PLAC or foreig country). C Ry? <br />I F$loomin ion l�ebr <br />a $ - -- -- -- c .. -1 -- <br />W �� 13. FATHER'S NAME 14a. MOTHER'S MAIDEN NAME 146. NAME OF ]IUSBAND OR WIFE <br />F Y Fr' ; )- -- - - - - -- - -- <br />Av � W. H. Finch. <br />~ > ° 15. WAS DECEASED EVER IN U. S. ARMED FORCES. 1 16. SOCIAL SECURITY 17 I <br />rn . <br />_ INFORMANT'S NAME or Signature fi Address <br />r3 a ,(If yea give war or dates of service)' <br />ervice NO' <br />W. Li. Finch, Gr&nd island <br />:W' m 18.e CAUSE-OF DEA _ -.,- <br />Y yob <br />EQ - -- - - Nrbr <br />.� � MEDICAL CERTIFICATION � .Interval Between <br />a J c Enter only one cause Tc`71. DISEASE OR CONDITION Onset and Death <br />a3w line for (a), (b), and (c) DIRECTLY LEADING TO <br />� DEATH* ( a4 <br />s.t �A1................ ........................... <br />................ <br />*This does not mean the ANTECEDENT CAUSES <br />Q'r a mode of dying, such as: DUE TO (b) <br />i :.I heart failure, asthenia, ....._ .............__..._.... ................._............. <br />wo ° etc. It means the die - rise id conditions, if any, t giving <br />jit v oU r+I rise to the above cause (a) stating <br />v the underlying cause last. DUE TO (c). <br />Q �' . ....... .... ..... ...__ .�.. <br />p'� ease, In ur or comp tca -�, <br />a u tion which caused death.11 II OTHER SIGNIFICANT CONDITIONS ' <br />Conditions contributing to the death but not <br />o � � a, F-i <br />related to the disease or condition causing death. <br />19a. DATE OF OPERA- 119b. MAJOR FINDINGS OF OPERATION <br />TION 20 AUTOPSY? <br />4 > F <br />in or ebout� ❑ <br />Yes No . -- <br />yy v 21a. ACCIDENT (specify) ' Ib YI,ACE OF INJURY e.g., 21c. (CITY OR TOWN <br />- - SUICIDE I - ;home, farm, factory, - street, office bldg., etc.) ) (COUNTY) (STATE) <br />o E While at Work (If rural nrex, write RURAL) <br />& 21d. TIME CI.(Month) (Day) (Year) (Hour) 31e. INJURY OCCURRED � 'if. HOW DIU INJURY OCCUR? <br />W Y, ) <br />o <br />INJ[JRY M. Not While at Work ❑ <br />k« 22. I hereby certify that I attended the deceased from.... , 19- to .._....... 19 that I last saw the de- <br />ceased alive on ._... ..., 19 and that death occurred at........ .7n., from the causes and on the date stated abr ve. <br />g, <br />23a. SIGNATURE (Degree or title) 23b. ADDRF `S <br />K F. Mc Dnrmott. MD Grand gland llebr 23e. DATE slcNEn <br />�O - Feb.l6 /5fl. <br />y a 24a. BURIAL 24b. DATE 24c. NAME OF CEMETERY OIt CREMATORY ` 244. LOCATION (City, town, or county) (State) <br />CREMATION ❑ l Feb. tJ 9- I 1'752 Gibbon L SPA � r i <br />1- ° °u REMOVAL XI(Specify) . • �Ti N y - GYbbon, 1Vebr.. <br />a �l <br />DATE R1 C D BY LO( AL ARE( IS�TRAR'S SIGNATURE fU1REG R'S 9IGNA fiiJ�E�p�7jA}g! 1 <br />z RE . WhitC � � <br />ITI <br />nL <br />7. <br />ti (J <br />A <br />e`� <br />r msµ, ».•°„�. <br />