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<br />214. ACCIDENT 21b PLACE OF INJURY (e.g., in or be, .21'. �CITY'OR_TOWN) (COUNTY) (STATE4
<br />SUICIDE If rural e., write RURAL)
<br />HOMICIDE 'home, farm, factory, street. office bldg., etc.)';
<br />___
<br />)i 21!��,INJURY OCCURRED" i
<br />21d. TIME (Month) (Day) (Year) (Hour 'if, HOW DID INJURY OCCUR?
<br />OF
<br />INJURY Not While 4t Work
<br />22. 1 hereby Certify that I attended the deceased vt that I last saw the dc-�
<br />ceased alive on../ 19,57.7., and that death occu"ed at,9.1 from the CaUSCS and on the date Stated above.1
<br />-13 -- -----
<br />'Z j 23a.ISIGNATURE
<br />(Ileg- or tAle) I 23b. ADDRESS 23c. AT SIGNED
<br />Iy/
<br />24.. U JAL V
<br />2111, "ATI, 1 24,. IIJAME OF CEMETERY OR CREMATORY 24d. LOCATIO (City. town, or c t I late)
<br />M
<br />CREMATION
<br />of REMOVAL 2-6-6,' G ?'871 , i Si a, !'I Grand 1Siaii� "E'S P.
<br />ArX� ',7WN;^: 25. FUNERAL DIREcTOR'S SIGNATURE ADDRESS
<br />A T �l ..A
<br />IV8)
<br />i FH�798 KLV. STATE OF NASKA
<br />STATE
<br />• DEPARTMENT OF PUBLIC HEALTH, MW-
<br />EDUCATION AND WELFARE OF EMALTH
<br />Bureau of V11W StatIsUce
<br />BIRTH NO. 126......_ CERTIFICATE OF DEATH
<br />-STATE FILE NO
<br />—
<br />-inatitutionj
<br />1. PLACE OF DEATH
<br />2 U UA
<br />* U UA ES' residause
<br />..COUNTY
<br />6. STATE b.COUNTY
<br />IJTAT ' ' "'
<br />I Nebr. h a Vef-re gdasigalon).
<br />T
<br />b. CITY (if outside corporate limits. write Rural) r. L E N G T H 0 r. CITY (If outside -rmr,w limits, write RURAL)
<br />u' OF r. 0 1 " net'
<br />0 0 - C
<br />OR STAY OR Grand -Lslana
<br />T Grand Island TOWN
<br />TOWN
<br />OW
<br />�R
<br />T.
<br />d 'I' -A. tree, d "I
<br />FULL NAME OF (If not in hospital or institution, 91,e street d. STREET (If rural, location)
<br />give
<br />H p L
<br />OS
<br />HOSPITAL OR addrsas) ADDRESS
<br />OS -TA ADDRESS
<br />INSTITUTION K" T.,
<br />z INSTITUTION Lij t he-a ii- I - , t, I
<br />It - _ 21 _J_1_Ln_
<br />i I,
<br />3 NAM -
<br />3. NAME OF (First) b. (Middle) _` 4. DATE (Month) (Day) (Y•ar)
<br />DECEASED
<br />DECEASED
<br />OF
<br />Print) A u g'i s L DEATH
<br />TYP_-_-r "I ____ ___ ---I- __ - __ - 1' 7
<br />RACE 7.
<br />6. COLOR or
<br />5. SE�' UTW1ED 9. JAG (I. yr..
<br />E. NEVER MA 11
<br />WIDOWED, BIRTH Under I Yr. . lit Under 24 H-
<br />DIVORCED 1 -1 birthday) M..
<br />("", Days Hour Min.
<br />1 �' � I
<br />to.. USUAL OCCUPATION !Give kind, of workj 10b. KIND 00F .3f BIRTH (City, town or county) (State[12. CITIZEN OF WHAT
<br />even NESS It.
<br />R
<br />done during meet of working life. ret red) INDUSTRY PLACE or foreign country) COUNTRY?
<br />:Y tl tlSew Fe
<br />13. FATHER'S NAME _F14.. MOTHER'S MAIDEN NAME
<br />r3 1 'In ft'! I fit S t
<br />16. WAS DECEASED EVER IN U. S. ARMED FORCES? 16. SOCIAL SECURITY 17. INFORMANT'S NAME or Signal- & Add...
<br />(Yes, no, or unknown (It Yes. give war or dates of .-der NO.
<br />No 1
<br />18. CAUSE OF DEATH! MEDICAL CERT1M1CATjbN
<br />af Belkj�
<br />E r only one cause ne, I DISEASE OR CONDITION
<br />• a for (a). (b). and
<br />(c) DIRECTLY LEADING TO DEATH-
<br />Oosat/.� Death
<br />ad ANTECEDENT CAUSES
<br />needs u I.,, h ..I DUE TO (b) ........................
<br />heart failure.
<br />ahthenbs- 1 Morbid
<br />d condition.. if any giving
<br />:tl*., fl.tJ.'sen, 11 - I rise 1. the above r.... (a), stating
<br />" or cOmP]ic& the underlying cause 1-1.
<br />ti.. which ..oerd det,� DUE TO (r) ...... ......
<br />if. OTHER SIGNIFICANT CONDITIO
<br />SI-171 NS
<br />C-diflem° r..trib.1i.g to the death but
<br />*I,td 1* th ll,**,* or o"dlll*" I
<br />AUTOPSY?
<br />194. DAIT OF OPTION Ai6ft FINDINGS OF OPERATION
<br />19b.
<br />We E] No
<br />
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