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<br />i PHS- 798(VS) REV. 7 -53 STATE OF NEBRASKA
<br />DEPARTMENT OF PUBLIC HEALTH, DEPARTMENT OF HEALTH i
<br />EDUCATION AND WELFARE
<br />Bureau of Vital Statistics
<br />BIRTH NO. 126........ CERTIFICATE OF DEATH STATE FILE NO .. ...............................
<br />a. Hall a. STATE JrTC br „�.� b COUNTY Iikllbefore "admiasien)
<br />b. CITY (If outside corporate limits, write Rural)' c. LENGTH OF CITY (If outside corporate limits, write RURAL)
<br />OR TOWN Grand I Sl4nd srnY G r3 TowRlf`yr is nd I S1 and. d. FULL NAME OF (If not in hospital or institution, give street 1c.
<br />d. STREET (If rural, give location)
<br />HOSPITAL address) ADDRESS
<br />INSTITUTION i r, j-. 919 �rl°Iit 7th St.
<br />3. NAME OF a. (First) b. (Middle) c. (Last) q. DATE (Month) (Day) (Year)
<br />DECEASED i�'illlar� Robert I::C OF t t
<br />1 Corm�ck
<br />Type or Print) DEATi f-P � • 4 • 1906
<br />5. SEX 6. COLOR or RACE 7. MARRIED, NEVER MARRIED. 8. DATE OF BIRTH 9. AGE (In yrs. If Under 1 Yr. If Under 24 Hrs.
<br />IDO ED, DIVORCED (Specify last birthday) Mos. Days Hours Min.
<br />rle White I' rr`ied, ov. ?, 189 0
<br />lOs. USUAL OCCUPATION (Give kind of work 106. KIND OF BUSINESS 11. BIRTH- (City, town or county) (State 12. CITIZEN OF WHAT
<br />done during most of working life, even if retired) GuatliflINDUSTRY PLACE Ans�rpts�'eigpl ') COUNTRY?
<br />� , � 1�,C�r.. r
<br />13. FAT EA'S NA 14b. NAME OF HUSBAND OR WIFE
<br />James Il:c Cormock Lillie Rucher I11c Corra:7431 Ednk I1-n Cormack
<br />15. WAS DECEASED EVER IN U. S. ARMED FORCES? 16. SOCIAL SECURITY 17. INFORMANT'S NAME or Signature & Address
<br />(Yes, no, or unknown (If yes, give war or dates of service
<br />NO.
<br />Yn s
<br />18. CAUSE OF DE H MEDICAL CERTIFICATION lv Jlnterval Between
<br />Enter only one cause �� I. DISEASE OR CONDITION ebr Onset and Death
<br />line for (a), (b), and c) DIRECTLY LEADING TO DEA H•
<br />A r * � r..t.....D.-taaa.l ...........3....7j.. n ,q
<br />*This does not mean the ANTECEDENT CAUSES
<br />modeof dying, such as DUE TO ( b) ..................................................................... ...............................
<br />heart failure, asthenia, Morbid conditions, if any, giving
<br />etc. It means the dis- rise to the above cause (a) stating
<br />ease, iniury, or complica- the underlying cause last. DUE TO ( c)-.- ................................................................ ...... .........................
<br />tion which caused death. - -. -- -. -_- ._
<br />II. OTHER SIGNIFICANT CONDITIONS
<br />Conditions contributing to the death but not
<br />related to the disease or condition causing death.
<br />19a. DATE OF OPERA-1 19b. MAJOR FINDINGS OF OPERATION
<br />20. AUTOPSY?
<br />Yee ❑ No_2
<br />21a. ACCIDENT (Specify) 21b. PLACE OF INJURY (e.g.. in or about 21r. (CITY OR TOWN) (COUNTY) (STATE)
<br />SUICIDE home, farm, factory, street, office bldg., etc.) (If rural area, write RURAL)
<br />HOMICIDE
<br />21d. TIME (Month) (Day) (Year) (Hour) I 21e. INJURY OCCURRED 'l If. HOW DID INJURY OCCUR?
<br />OF While at Work ❑
<br />INJURY m. Not While at Work ❑
<br />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 .............. m., from the causes and on the date stated above.
<br />23a. SIGNATURE + (Degree of title) 23b. ADDRESS _ 1V 13c. DAT SIGNED
<br />Reber., F. Munch. 10. Grand jsl.4,nc ?. r,i�r S.pt.4/o5
<br />- - -- ---- - - - - -- -
<br />24a. BURIAL 24b. DATE 24c. NAME OF CEMETERY OR CREMATORY 24d. LOCATION (City, town, or county) (State)
<br />CREMATION ❑ Ansley Cemetery nsle /, b i
<br />REMOVALrVpe _ „`�
<br />DATE REC'D BY LOCAL G ST A IGNATURE 25. FU 2A D E S SIGNATUR DRES
<br />REG. G. �. 1Y11t(� id ..D /.w L' i.it // '�
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