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PHS-798(VS) REV. 7-63 STATE OF NEBRASKA 77 <br />DEPARTMENT OF PUBLIC HEALTH, <br />EDUCATION AND WELFARE DEPAReau of TMENT Statisti Vital OF HEA cs n a <br />d <br />Bur <br />BIRTH NO. 126___.____ CERTIFICATE OF DEATH STATE FILE NO._ ............. ..._. <br />1. PLACE OF DEATH 2. USUAL 111!�l r (Where deceased lived. If institution: residence <br />a. COUNTY Hall a. STATE b. COUNTY Ij before admission). <br />b. CITY (If outside corporate limits, write Rural) c E N G T H OF c. CITY (If outside corporate limits, write RURAL) <br />6 co: OR STAY OR OR <br />W A T OWN Grand lsl,.nd, TOWN <br />d. FULL NAME OF (If not in hospital or institution, give street d. STREET (If rural, give location) <br />6 HOSPITAL 0' R address) ADDRESS <br />z INSTITUTION i 4�';4 N '-'reenwicll <br />0 (First) b. (Middle) <br />3. NAME OF a. c. (Last) 4. DATE (Month) (Day) (Year) <br />DECEASED I OF <br />(Type or Print) John Htrrna n I )MATH Au st4.1956 <br />h m s <br />ED, NEVER MARRIED, Under (1 Under 24 <br />0 SE 6. COLOR or RA17. MARRIED, ED, 8. DATE 0 BIRTH 9. AGE ( n yrs. If <br />WIDOWED DIVORCED (Specify) last biXtj1day) D o Days Hours Min. <br />'4 2 <br />fx Y, <br />Q ral w,lite HarrleA unG 1 189 <br />x 10a. USUAL OCCUPATION (Give kind 10b. KIND OF BUSINESS 11. BIRTH- (City, town or county) (Statell2. CITIZEN OF WHAT <br />eve if of work <br />ST <br />.4 done retired OR INDUSTRY PLACE <br />.4 �uring most of working life, eve o UNTRY? <br />�iforjf; gFtry) <br />P; .trice Foods Co E d <br />runs w) rt a u i o n <br />13. FATHER'S NAME 14a. MOTHER'S MAIDEN NAME 14b, NAME Oil HUSBAND OR WIFE <br />Louis Lehms Amelia Thoene usie lAhms <br />0 <br />'Y 0 M <br />15. WAS DECEASED EVER IN U. S. ARMED FORCES? 16. SOCIAL SECURITY 7. INFORMANT'S NAME or Signature & Address <br />ab <br />0.9 (Ye ,�no, or unknown � (If yes, give war or dates of service) N <br />9:L a L't <br />0 Susie Lohms, Grand Island <br />OEZE <br />CERTIFIC <br />f4 18. CAUSE OF DEATH MEDICAL Interval Between <br />Z �=z Enter only one cause Pei Onset and Death <br />Ai line for (a), (b), and (c) I. DISEASE OR CONDITION <br />DIRECTLY LEADING TO DEATH- M ocardial In°�zr�-tlon <br />(a) y ..................................................... n� ................................................ <br />A :3-W 00 ................................... <br />W OAW� <br />-This does not mean the ANTECEDENT CAUSES <br />mode of dying, such as DUE TO (b) .............. <br />'0 heart failure, asthenia, Morbid conditions, if any, givin <br />g g <br />etc. It means the dis- rise to the above cause (a) stating <br />EV (D - V ease, injury, or complica- the underlying cause last. DUE TO (c) .......... .................................................... ..... <br />- Q tion which caused death. .......................... <br />II. OTHER SIGNIFICANT CONDITIONS <br />C O nditions contributing to the death but not <br />Rai 'o related to the disease or condition causing death. <br />V, 19a. DATE OF OPERA- 19b. MAJOR FINDINGS OF OPERATION 20. AUTOPSY? <br />TION <br />Yes E] No.0 <br />21a. ACCIDENT (Specify) 21b. PLACE OF INJURY (e.g., in or about 21c. (CITY R TOWN) (COUNTY) (STATE) <br />SUICIDE home ' farm, factory, street, office bldg.. etc.) (If rural area, write RURAL) <br />HOMICIDE <br />0 <br />21d. TIME (Month) (Day) (Year) (Hour) � 21e. INJURY OCCURRED 'if. HOW DID INJURY OCCUR? <br />OF While at Work 11 - <br />in. Not While at Work <br />.0 INJURY <br />22. 1 hereby Certify that I attended the deceased from.. ..... 19........, to. .... .. ...... 19.._....., that I last saw the de- <br />all ceased alive on ................. 19 ...... and that death occurred at ..m., from the causes and on the date stated above. <br />23a. SIGNATURE (Degree or title)� 23b ADDRESS 23c. DATE SIGNED <br />Dr- Lon Gratrid, I sl and. <br />.0 24b I , - BY 24d. LOCATION City, <br />19 P �_ town-, ti <br />or count y fate <br />24a. BURIAL CEMETERY OR CREMATORY <br />z 141 <br />CREMATION E] Au� i emori;U Pai 'emetery Gj;-g�d Isl"nd <br />4 <br />.0 0 REMOVAL p (Specify) A <br />at <br />-DATE E CT 0 R'S' =SU <br />RECD Bf6LOCAL � REGISTRAR'S SIGNATURE RE <br />REG. • • �,Vhjte pk�-' � <br />r, E�'Ao P <br />1//' 'Mll V16 " - - <br />
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