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..................... <br />1. PLACE OF DEATH 't^ _._ _ -- <br />I .. USUAL RESIIiF.NCh (Where deaenad Ilved If lartitua�n> <br />COUNTY h, • 4f� I. e. STATE y $11 b COUNTY N e h �ro <br />t .amte.ba). <br />7 11 <br />yt h. ('17'Y (If nut I or {wrxte Iimit., wrke Rural) c. L E N C T H OF c. CITY (if .­id, porn[e Iimit., write RURAL) <br />(1R SPAY OR <br />\ \ \ \` TOWN Gran;i island _ TOWN Gxand `_s1fl.Cls� _- - --_ -- <br />d. 1LI. NAME OF 11f not in hnxnitnl or Institution, Rive t t "d. STREET (If royal, clue ]Doti..) <br />I IOSPITAL OR e1dre.0 ADDRESS <br />NSr7TUT1.ON Lutheran nos ° ( st `-harles <br />P — _ —_ <br />$, A NAME OF x. IFIrstJ b. (Middle) (I.e.O- iJ� {r 4, DATE (Month) (Day) (Year) <br />h UE('F.ASEII OF <br />(T- m- - Plu ❑ t nL.:ry t,i11 uhlanit nEATHJaiL1 195F, <br />5 SEX ' 6 COLOR o RACE MARRIED NEVER MARRIED 18. DATE OF 13IRTHI 7 AGE (I y If Under 1 Yr. 1f Under 24 Hra. <br />•tjR I WIDOWED DIVORCED (hi ty)" 1 I the y) Moe. Uayn NOLra Min. <br />e reed 7 -c7 lo7d 1 /� _ <br />{ 1ox USUAL OCCUPATION Div. kind of work lab. KIND OF BUSINESS! 11. BIRTH (City, town county) (Slate,12. CITIZEN OF WHAT <br />= done during most of woekinu I ( .ro if 1 ed) OR INDUSTRY PLACE t it <br />re lm mu"try) COUNTRY? <br />?, dte.tiou pc'_'a. _r Gflsohae Dctpaa i� uarl ^art•: - -I - <br />1M1 FA7'1IERS NAME '•14.. MOTHER'S MAIDEN NAME ICb, NAME OF HUSDAND OR WIFE <br />V <br />Anna L. Scurnxle _n::hmann <br />I,. <br />WAS DECEASED F\FR IN U S. ARMED FORCES 16. SOCIAL SECURITY 17. INFORMANT'S NAME or S tore <br />ld k Addreea <br />Iko— (If yr., Irlve — or d— of Iorvlce) NO. lrn ' -- n <br />rs 71nna Hohmann "rand Isle <br />E' CAUSE of uF:ATII MEDICAL CERTIFICATION - In9 v Betwwn <br />h.. dr on. ruuno DeI Onwt and Wath <br />hn f tut. Ib) and Tel 1. DISEASE L CONDITION <br />{\ DIRU(7'LY LEADING TO IIF.ATFI• <br />-Thin does not meen the ANTECEDENT CAUSES <br />mode of drin a, xurh se DUE TO (h). '/d(rt ,e- •,�. <br />heart fsliu rt, a.thenta, 1lorbid condition., if <br />etc It nx the die- rise to the above °ny' [ivin[ <br />ens <br />inJury. or cantDlica- coon. (a) elatln[ <br />tk: hi h eeu.ed de. the underly ln[ NIFI tut. IIIE TO <br />H. multi t SI(,NIF'IC.. CONDITIONS <br />UITIONS <br />('undid I. contri —e , to the de.th but not ./1 �•'' " � <br />releted to the di.eue or condition <.utln[ deelh. y"�/�- <br />_ T ON �7 <br />1'Jn DATE OF OPERA I lab MAJOR FINDINGS OF OPERATION I- U <br />A TOPSYf <br />� Yee No � I <br />"1 n. <br />ACC DENT' (1njfr) .1l.. 1'I.,10E: (IF INJURY le.A., i r n6rut ,Ir. IC.ITY OR TOWN) (COUNTY) ,�- - -- <br />SUICIDE h��me. form, Lirtury, xt rrrt, nffirr bid[., et r.) 11f r`ul x rite RURAL) ) (STATE) <br />2 1 . I . 'TIME I M i i n t h ) (Dxr) (Y ' . r ) (Hour) -1 INiJURWnr){CCURRED _If. HOW DID INJURY OCCUR' O E' <br />IN'J f'RY �--'� m. Nit While nt Work ""�� <br />'^ -.1 hrrcbp ecrtifu 'j, ot ettrndel the dc—cd Jron�2lr �f — 19 .., to_� ty�.,.6, that I cast saw the de- <br />and that death t occurred ag - -u 1?1 , Irm the tons and on the date stated above. <br />'3x }J{(.N1 Kf; IIk <br />i <br />'-'.3 1, -jtr t L 9t1GN ED <br />D TE ldu. BURIAL Al AMP OF CEMETEI Y (tit CREMA 0 t id. LOCATION lCit- <br />(RFM\TION ) (State) <br />o REMOVAL 7 ( - i <br />u. :' . "1 - "::IG iat1 1r bv- <br />Yr{t".fi.. Liv1Lli\I SIGNATORF .. <br />• DATE RE('D Ii 1, t 't` U DDRFCC - - - <br />JUL <br />Issued November 23, 1956 <br />I <br />