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STATE OF NEBRASKA <br />DEPARTMENT OF HEALTH <br />DIVWm of Vital Statsilra <br />R)! STANDARD CERTIFICATE OF DEATH <br />-1E AtENT Ot' C(1NN US <br />In'ItEAU ur''IUE cFSSUs <br />d,I sl Bea itl Na..__. _ ..... ... S44 FYI. N­_ ......................._.... <br />. 1 t. 1'1.:\t'E OP UE,\Tlir T. USUAL RESIDENCE OF DlAEASED: <br />>,I 1 •vul .... . .:.�. a.i _ ... . ... (.) 344 C J I._. • !l P 11 <br />.._ ....... (h) Comty .... <br />.. <br />h f h- 1 If l t111 i t l 11 1 14 RURAL) (e) CiIY t ... ti.. Il V ..4.':. } I O <br />' (If 41de 60, a 4 Il�t 14 RURAL; <br />1 <br />�� I( n� h pl 1 ti I t t umbe I atlonl (d) StrtM N i 't.. _.1 A.1 �kl ...... .. ......_. <br />(It curd ¢I I d ) <br />1 1n,r h .f nrv) . In h.aN41 or Iv.tit ._... <br />........... <br />O (e) it lorelan Lore. bow long iv V. S A.. ...... .. ...._years. <br />MEDICAL CERTIFICATION <br />de h. <br />Month <br />t,;, da .A•. -A-7— <br />E 1 .. h <br />-�� . _ .. minub .. <br />n �1 rrl � ar. ., � t. ...._.i c, j..l.j_l ....t ., �f70 r M. <br />3(b) If r t a.. -- 1 I hertby —ill 11.1 I 11 d d th d rx I Irom rl.../ <br />10 lo__ <br />1 fill) Single, w d ed rri d - that I I.ti t jaw hA4aA. I .,_.. IO <br />1 n.1 dc.th occurn.l no th d to and h rated bo D <br />I n f l :1 J f 6() Ago of haab md <br />If 11 Yr r{ <br />1. 1 <br />=: y <br />R \CF: Y _ Il ) <br />I If Im ..b than <br />. . daY _ <br />Due I`- ... . ....... ..... ...._.. <br />....... ..'... ...... <br />j.• .�. Itinhtl - Other condition. <br />e v` ..I .4 1 an ... (lvclude Drcgnancy within 3 months of depth) <br />1 ro PHYSICIAN <br />154te or torelgv rouotrY) <br />..i _ _. .. ..._ ....... <br />^. .. •...., Mej.r f1.Jin <br />„7-j ", Underline <br />id. th <br />n auee 4 <br />r ur ..0 1 >) Ib.nlr, f ,r \n tnun.rj' O f ..... '11h r.ell y. eta <br />cause fill i be <br />� 1 I❑ 1 1 ,, �. ... ( a den n 4rnal - <br />e u r t >) stpya [ gn coon r l n rd t de .mldde ( Rr) ... <br />I .r <br />a..,, ..... .................. <br />occurrence .................. ........ .... <br />1) Whew did iviur ac 7.. <br />/ ��1)to or tow.).•..... (Co ty).. (Si �iel <br />a. II ii '1 M ,tlrl (I ) (Y Id) Did injury car (n /.bout home. on term, le lial.Ari.l 111— In <br />public III—? ... _ �/ .. .. ... .... .... <br />f f.t L 11 1 ,. (SUrrifY type ut Dln ) <br />w <br />II (b) Id Wbiie t ly;. e) Meay. of mMjV Y ........... .. <br />D <br />... <br />_Dgte I¢ ed. � e ... �, <br />i <br />x�r9. <br />�t <br />6`1 <br />Al <br />