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pHs- ',9SiVS) REV. 7 -53 STATE OF NEBRASKA <br />DEPARTMENT OF PUBLIC HEALTH, DEPARTMENT OF HEALTH <br />EDUCATION AND WELFARE Bureau of Vital Statlstice <br />BIRTH NO. 126 -------- CERTIFICATE OF DEATH STATE FILE No......_......._ ..... ................. ......... <br />....' <br />_ - <br />-1. PLACE OF DEATH 2. USUAL <br />e D r (Where d sed <br />aye I admission). USUAL RESIDENCE lived It inacitun identt' <br />e. COUNTY Bail l! a STATE b COUNTY H t - <br />I <br />fl) b. CITY (If outside corporate limit. write R-1) 3TL N C T H OF r. CITY R (If outside corporate limits, write RURAL) <br />r OR <br />ZJ...... TOWN GraLu - Shad _ _. TOW*! i1ruid- .la and <br />d FULL NAME OF (if n t in hospit I ti[ul Nave •t et J. STREET I Rive loc Lion) <br />HOSPITA I, OR 5 t r fl Y: C 1 11 l i jJ addre ) ADDRESS FRS t First St. <br />Z INSTITUTION 'S"^�`^'' <br />__ <br />- e IF'intl -- -- -6. ( Middle) - -- - -c. (La +t) - --- - -- <br />4. DATE (Month) (Day) (Year) <br />v 3 NAME OF <br />&' DE(F:ASF:D OF ' <br />ITyv ,F ''.1 amie _ E[,,�e r DEATH N_OV 25j�_ 195 <br />5 SEX 6 COLOR or RACE ]. MARRIED, NEVER MARRIED, 6. DATE OF BIRTH 9 AGE (I y It Und 1 Yr F, Under 2d Hre.: <br />WIDOWED, DIVORCED (Sp. Ify) 1 irthd Y) Mos. D y � Hours I M{n. I <br />s FE male hits Married b -29- 18_ &_Y <br />P work Lob. KIND OF BUSINESS I1. BIRTH <br />t0 USUAL OCCUPATION IG k J of - (City t or county) (Stet r12.. CITIZEN OF <br />do a during most f orktng I if,. even if retired) OR INDUSTRY PLACE foreign rounI e b COUNT IV? <br />WHAT, <br />HOnsei:ife _ home yerrick Count! y_ k'a U- <br />FATHER'S _. <br />FATHER'S NAME lda. MOTHER'S MAIDEN NAME Idb. NAME OF HUSBAND OR WIFE <br />= _C.ars_ten Bosselman .Aar e Koch tlen� J��e.rs <br />15. WAS DECEASED knownEVER 0. give S. ARMED FORCES? 16. SOCIAL SECURITY IZ. INFORMANT'S NAME - Signature A Address <br />(Y no, or un war or o service) No HeprS Eggers_Grand lslc.nd <br />i 4;1-15 E '" (a) (b D dAT; 1. DIRECTLY CO DI TO DEATH• Cd iClll0[Rd tO$13 __..... O Net and D:�,b line E MEDICAL CERTIFICATION <br />Thins does not each the' ANTECEDENT CAUSES e f dying. a DUE TO (b)...t the edis- Morbid ondition,. if , Siring <br />e an means r t the in (astating in y, or eompliu- the denying Wt. <br />�° lion caused death. DUE TO le)........ ....... <br />r If OTHER SIGNIFICANT CONDITIONS _- - - -- - - - -; <br />�$ U d i a on t b tl g to the death bat not , <br />related to the di or eo litl on ausing death. <br />s 19e. DATE OF OPERA Ivb. MAJOR FINDINGS OF OPERATION <br />TION -- - - - "— <br />20. AUTOPSY' ' <br />,E t (II rural area, write RURAL <br />E _ _. . _. _ _ _ _ Yee [I No � <br />21.. ACCIDENT (Specify) 216. PLACE OF INJURY ( 1 6outl _IC. (CITY OR TOWN) (COUNTY f <br />SUICIDE .home, farm, factory, street, office bldg., etc.) ) ) (STATE) <br />HOMICIDE _ <br />INJURY (Year) - - - - - ._.. _. <br />r e '21 -INJURY OCCURRED 21t. HOW DID INJURY OCCUR2 <br />m OF - - -� Wh 1 at Work 0 <br />21d. TIME (M th) (Day) (Y ) (Hour) - -� <br />° Not While at Work Ej <br />22 I hereby certify that I attended the deceased �..., 19.56.., that I last Saw the _ _ eased rom..3 29 _____ _- 28c. DATE 9 above <br />r *.A <br />AL 2db. ;)nTF; d tha death occurred at ifilJ. m Jrom fhe causes and ott tbhe dat 11 a27 56 Ve _d alive on N.t]Y..2S 19.. 6 att 2 URE (Ik o RILL) 28b AD ES$ - - <br />2 x e. NAKN OF CEMETERY OR CREMAT =and y, town, or county) (State) A +IOi ?� .(../ yl,zv -_ and - A w land Nebr _ <br />= ao _REMOVAL n fy' If( ( <br />DATE REC'D BY LOCAL R f':. S 5[ 'N. RE 28. FUNERAL DIRECTOR'S SIGNATURE ADDRESB <br />F nra 7_— —L_ _, L✓ gston- SondermaUn Grand TRiRt1 <br />3�.5 <br />61,111 <br />r I, <br />I� <br />i <br />