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4/12/2012 10:42:10 AM
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004-313
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W <br />0 <br />W <br />6 <br />W a <br />II t„,p0d <br />c5 arza <br />z yx� <br />/w .c alb <br />ii a e7iro <br />'dam o <br />Phi A� E <br />u <br />of a <br />r <br />&� k <br />U <br />O y <br />aw V <br />^0 A <br />a a <br />z N <br />PHS- 798(VS) REV. 7-68 STATE OF NEBRASKA <br />DEPARTMENT OF PUBLIC HEALTH, <br />EDUCATION AND WELFARE DEPARTMENT OF HEALTH e n <br />Bureau of Vital Statistics . e dde s <br />BIRTH NO. 126 -------- CERTIFICATE O <br />OF DEATH STATE FILE NO ................. ............................... <br />1. PLACE OF DEATH 2 <br />2. USUAL RESIDENCE (Where deceased lived. If institution: resider <br />a. COUNTY Hall a <br />a. STATE Ne br b. COUNTY Hailifore admissim <br />_b. CITY (If outside corporate limits, write Rural) c <br />c. LENGTH OF c <br />c. CITY (If outside corporate limits, write RURAL) <br />TOWN Grand I la d S <br />STAY <br />TOWN <br />d. FULL NAME OF (If not in hospital or institution, give street d <br />d. STREET (If rural, give location) <br />o HOSPITAL OR address) A <br />ADDRESS 2 <br />x INSTITUTION 9520 Went John at <br />252 <br />3. NAME OF a. (First) b. (Middle) c. (Last) - 4 <br />4. DATE (Month) (Day) (Yeas <br />D DECEASED T� Glen a <br />Nov. <br />Type or Print) D <br />DEATH N <br />a <br />6. COLOR or RACE 7 <br />7. MARRIED, NEVER MARRIED, 8 <br />8. DATE OF BIRTH 9 <br />9. AGE (In yrs. I <br />If Under 1 Yr. I <br />If Under 24 H <br />WIDOWED, DIVORCED (Specify) l <br />last birthday) M <br />Mos. Days H <br />Hours Min <br />10a. USUAL OCCUPATION (Give kind of work l <br />lob. KIND OF BUSINESS 1 <br />11. BIRTH- (City, town or county) (State 1 <br />12. CITIZEN OF WIL <br />i do a during moat of working life, even if retired) O <br />OR INDUSTRY P <br />PLACE or foreign country) C <br />COUNTRY? I <br />13. FATHER'S NAME 1 <br />19a. MOTHER'S MAIDEN NAME 1 <br />19b. NAME OF HUSBAND OR WIFE <br />Henr M <br />Marjorie Fonda <br />i 15. WAS DECEASED EVER IN U. S. ARMED FORCES? 1 <br />16. SOCIAL SECURITY 1 <br />17. INFORMANT'S NAME or Signature & Address <br />(Yes, no, or unknown (If yes, give war or dates of service) N <br />NO. <br />11284 o s <br />s <br />18. CAVAIr OF DEATH M <br />MEDICAL CERTIFICATION g b r Interval B <br />Betwei <br />Enter only one cause peT I. D <br />DISEASE OR CONDITION O <br />Onset and Des <br />( 8) ........................................................................................................... ............................... <br />*This does not mean the A <br />ANTECEDENT CAUSES <br />mode of dying, such as D <br />DUE TO ( b) ..................................................................... ............................... <br />" <br />heart failure, asthenia, <br />Morbid conditions, if any, giving <br />0 etc. It means the dis- M <br />rise to the above esue (s) stating <br />ease, inJary,.or compliCa- r <br />the underlying cause last. DUE TO (c) . <br />0 tion which caused death. t <br />.. <br />II. O <br />OTHER SIGNIFICANT CONDITIONS <br />V' C <br />Conditions contributing to the death but not <br />,- I - - <br />x +' <br />I <br />Cd <br />x C <br />OI CH Cd <br />O It <br />4-) Z 0 <br />0) 41 <br />U O • <br />W 1+ a) <br />t1 Q <br />w Q CQ 0 <br />r <br />7 <br />>, 'is <br />0 <br />c <br />ai -� <br />r <br />7 <br />>, 'is <br />0 <br />c <br />ai -� <br />
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