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a. COUNTY y i 17 ..Jr?'�`T -. b,., tOL;NTY before edm�.alon ).
<br />to ... �. E'L_i'. -ka 1. _
<br />b. CITY (If ,ut,id, corporate limits, wrltc R—D r L E N G T 11 OF r. CITY fit oul.ide corporate limit, ante RURAL)
<br />OR - SLAY (1 OR
<br />TOWN Lr.'! "iie^ TOWN �'�,.nli T ti
<br />d. FULL NAME. OF (If not in h . pital o e t t ton, ¢ treet. d. STREET - - - ural, Ike la•atlunl
<br />)IORPITAL OR U R'b "") ADDRESS Of r
<br />r rNSTrrD'nox J'. R lro- -d id lri, 1611 e .t John 3t.
<br />S. NAME OF a. (k at) b. (Middlrl. _ c. (l.asll - - _-
<br />OEC EASED 4. It: \TE IMonth) (prey) 1 nr)
<br />'e
<br />8' or Print) .t *le:= Dillard rutn(u: F J °n. ?C 195
<br />ITrV -_... DEATH -' f
<br />S. SEX '1, COLOR or RACE 7. MARRIED, NEVER MARRIED, 1, DATE OF BIRTH_ t AGE IIn )rs. If Under 1 Yr. �If Under 14 Hrs.
<br />(Spec fr) I
<br />WIDOWED, DIVORCED / - 4irthda)) Mo.. Ilay" Efour" Min.
<br />w _ n trrien 12/14 18FS t 7
<br />X Iu USUAL OCCUPATION I(. c kind f —k 10b. KIND OF BUSINESS I1. 111 I'1 (City. t ty) (St t 12. CITIZEN OF WHAT
<br />< 1 du 1 t of x k �r Itte,)c R �f 'et n- OR INDUSTRY PL1 L o f 1 LUj] \Tf2Y7
<br />m r_11 em. in ? . r . . a 1 rO�I r
<br />)I- ,a ours �
<br />13. FATHER'S NAME 6 J-!}, 14t. MOTHER'S MAIDEN NAME � 14h. NAME OF Fit SBANI OR WIFE
<br />o
<br />il.liar �'u F't_
<br />Lydia -1 s-,i, v 0. Futnar)
<br />Y%. 1S. WAS DECEASED EVER IN U. S. ARMED FORCES.' 16. SOCIAL SECURITY 1:. INFORMANT'S NAME. or Sig—ture @ Addrr""
<br />pr (Yee, n , or -111 yes. give wnr or date" of ""Ile) �. NO
<br />k wn
<br />m9
<br />=ixi)m IN CAUSE OF DEATH _ • -. 1 land
<br />MEDICAL CERTIFICATION Bet -
<br />3v E er only ), lc) R CONDITION
<br />O et ¢red D¢th Itne for (b), and 1.
<br />c
<br />DIRECTLY LEADING TO DEATH• �
<br />Ernes e 0 does.. m..h line ANTECEDENT EDk; N'P l'. \l;S};S �• -. {.
<br />�- mode of dyin¢, such es DUE TO, IU
<br />e-)z heart fetlure, a.thenia, 'r r
<br />ox Morhid renditions, if am ¢isin¢ ` r
<br />o ,0" etc. Ft "' the
<br />If r' a to the bove c se (n) et.'in.
<br />p o e se, fnlury, eo omplice- Lino underlrin¢ rauseu last. ��,)•
<br />n r r
<br />..V Bon whlrh ceu"rd death.. II[7F; TO ..
<br />oU >. _....
<br />y 11. OTHER SI(:NIiTCANT ('.De DI TI DNS
<br />Condd 1, cored. —en. to the death but o[
<br />eleced to the dl.eece �r condition rausin¢ death.
<br />,.p= 19a. DATE OF OF"ritA- Itch, MAJOR F'INDIN(:S OF OPERATION -- - - - ,' fiTOl'SY',
<br />3h.Y TION _o ,1
<br />Yos Ll No RI
<br />.1a. ACCIDENT (Stt ify) It PLACE OF INJURY Ieu n r al—I '_le il'1'Y OI< fD \1 \1 (COUN "I'Y) tSTATE)p
<br />E SUIf.II h e, farm, factlry, et rcrt oUf, �bld¢, etc 7 It r rnl n r i write ILL 'ItA i.)
<br />HOMICIDE
<br />- 21d. TIME: (M,)nth) (Day) (Year) (Hour) tie. 1NJ URY OCfl: I2I❑Elt _I[. 1{U \L' DID INJURY Ol'C l'It'
<br />E _ UF• while at Wnrk
<br />s
<br />n INJURY m. Nnt. W(hile at \York
<br />o '2!. I hereby certify that I attended the drecascd frobt 7) to : -. _... 19 : y:, that I last saw the- de-
<br />ceased oir+e.�on i 19 _.. ., red that death occurred atr�l (4.p ausrs and on the date stated abnre
<br />_ � >» • 1>~�m the c
<br />29a. SIGNATURE (lteurm r title)- _36. 'fl D LbS 2 9r D \'I'F SIGNED
<br />24a. BURIAL 46. DATE A NAME OE CEMETERY OR CItF \1 \TORY �Cdl LOCATION 1(ity. loan aunty) (Sl te)
<br />i CREMATION
<br />E REMOVAL 7(Sprttyr1/25/56 sx,nd CeI ~e. an(i T:.lnnd, 1 :ebr :ka
<br />DATE RECD BY LOCAL 1?Er1STRA 'S
<br />'1tGNA F'UN'EHAI. Dlltyf OIt'J SIGNATURE ADDNEJS
<br />I��nw�er a //) ��e.:•_- �rnr..r_ il�t)r_
<br />a KGs
<br />
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