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C <br />C <br />J <br />C <br />R <br />° <br />ne <br />o� <br />E� <br />7"0 <br />° <br />E <br />IE <br />8 <br />a <br />I nATR RECD BY LOCAL I RFY 169"Mi R'S SIGNA <br />PHS- 798(VS) REV. 7 -63 STATE OF N101tA8tA w a7 !} [)(� (k <br />DEPARTMENT PUBLIC HEALTH. D � J6 <br />�,Nar <br />BIRTH NO. 126........ CERTIFICATE OF DEATH fIPATE MLE NO.._:_._ <br />1,,'PLACE OF DEATH <br />a. COUNTY Hall f ,. a A <br />SPATE 0. COUNTY Imh"s Nebraska <br />b. CITY (If outside corporate limits, write Rural) L E N G T H OF o. <br />CITY (It outside eurposat. Kraft., writ. RURAL) <br />SAY <br />Rural <br />TOWN <br />TON <br />d. FULL NAME OF (If not I. hospital or Institution, fire Rraat d. <br />STREET (ff ) <br />Song <br />x INSTITUTION Lutheran Hos ital id"'°") <br />ADDRFSB5 mi. O`i� a <br />$ S. NAME OF a. ("M) b. (Middle) c. (Last) <br />d. DATE (Month) (Day) (Year) <br />DECEASED or rint) Emelie Goods <br />DPOAFiTHHarch 7, 1954 <br />5. SEX 8. COLOR or RACE <br />1. MARRIED. NEVER MARRIED, <br />8. DATE OF BIRTH <br />9. AGE (In yrs. <br />It Under 1 Yr. <br />H Usdar N am <br />hite <br />WIDOWED, DIVORCED (9peelty) <br />_99_19nn <br />hat birth <br />55 <br />Moe Dtys <br />Hours Mls. <br />10a. USUAL OCCUPATION (Give kind o! work 106. E[ND OF BUSINESS <br />workinf life, even If ;J; d)1 OR INDUSTRY <br />11. BIRTH- (City, town or county) (Slate <br />PLACE totals. <br />12, CITI RN OF WHAT <br />C9UNTRYt <br />done during most of <br />or IXtry). <br />be <br />UWIFE <br />FATHER'S NAME IIa. MOTHER'S MAIDEN NAME IIb. <br />NAME OF HUSBAND OR <br />K e J hanna Zuehlke <br />Elmer Gosda <br />15. WAS EASE IN . S. ARMED FORCES? <br />16. SOCIAL SECURITY 17. INFORMANT'S NAME or S(snaton i AddMM <br />EVER <br />(Yes, no, ounknown <br />_ <br />er G Al Nebraska <br />16. CAUSE OF DEATH <br />MEDICAL CERTIFICATION Ingersoll <br />Batwesa <br />Enter only one uuaI I <br />DISEASE OR CONDITION <br />Owl aed Death <br />(' <br />line for (a). (b). and (e) <br />DIRECTLY LEADING TO DEATH• .• <br />-This does net mean<b It <br />meda of dyln[. u <br />ANTECEDENT CAUSES • e <br />..... ...................... <br />DUE TO (b) ..... ...... .. .... A.:tie.,,Sf{�f': ... <br />. <br />... <br />heart failure. asthenia. <br />Morbid eonditba ft any. firfni <br />ate. CIS, means the dla- <br />=111 <br />rice t. the abuts <am.e (a) statin[ <br />s <br />ease, DWn, or a- <br />tion which caused de0h. <br />underlylni ease wt. DUE TO (e)..._..... ... <br />. ....................... ............ ._...........:............_. ..... ' <br />11. <br />�QL x <br />OTHER SIGNIFICANT CONDITIONS <br />Conditions " tribmtin[ to tM death ►at at <br />related to the r <br />di<easa o eanditlon .Sass.[ 4.1h. . _ �._._ <br />MAJOR FINDINGS OF OPERATION <br />�• <br />20. A OPSY? <br />19a. DATE OF OPERA-! 19b. <br />TION <br />_ <br />'� I <br />___ _ _ <br />Yn ❑ No <br />21a ACCIDENT (Speedy) <br />^ <br />21b. PLACE OF INJURY (e.g.. In bout _le. (CITY OR TOWN) (COUNTY) <br />(STATE) <br />SUICIDE <br />HOMICIDE -�� <br />home, farm, factory, street, offiea bids., etc.) (If rural a write RURAL) <br />I T— rea' <br />URY OCU't�E:1fo D <br />21d. TIME (Month) (Day) (Year) , , HOW DID INJURY OCCUR? <br />Wor <br />OF While et k ❑ <br />INJURY �'-"' m. ( Not While t Work ❑ �-- -� <br />22. I hereby t t I attended the deceased from y 19AU to..3_% 7 <br />I; certify —TR ...., 19! 7 that I last saw the de. <br />ceased alive on.3716 ....., 1911., and that death occurred at;V,30. ,m., from the causes and on the date stated above. <br />2 SI TUBE ( RESS 28e. DATE SIGNED <br />UAAD <br />i <br />21e. BURIAL <br />2 1, A 24e /NAME OF CEM ECREMAT Y <br />21d. L [ • (City, town, or ooanty) (State) <br />CURIATI ❑ <br />S L1 Grand Island <br />Gradd Island, Neb. <br />S REMOVAL (Specify) <br />t0^ i <br />�i <br />I <br />L� <br />.Z/// <br />l <br />4 <br />f <br />