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n <br />�m <br />7 <br />�1 <br />i <br />0 <br />;9 <br />of <br />�o <br />m <br />li <br />g <br />PHB- 79e(Ve)REV.746 aTATn OF NiB$A6IIA a $5-00576 <br />DEPARTMENT OF PUBLIC HEALTH. p�Ag'I111'i' OF 1( <br />EDUCATvON AND WELFARE mYid2111 a! VNN araarue. <br />• �a cpRTIFICATE OF DEATH NPATa 1116.21 Me... <br />I. PLACE OF a a: <br />•• Hell <br />STATE NebZ'. A OOUMTT 4 t= .'.. <br />b. CIO (If out" emyorat. Hmlta, weft. Rural) <br />.. L 3 N 0 T H OF c. <br />CITY S (H = eorporab Ogty,a r14 EVAAL) <br />TOWN Alda <br />,TOWN At1 <br />d. <br />d. FULL NAME OF Of let In ir"Atal or '""lot' -' "-ad <br />rC�a��If6,�yoa <br />ADDRESS oilla�0 �•113Yie ) �. <br />) <br />=..TI. ONR trill, a Limit, <br />8. NAME OF a. (First) b. ( °• ( <br />d. DATE (Meath) (DU). (Year) <br />DECEASED <br />FrSrah Elisabeth Lar a <br />DEATH Juno 16 1955 : <br />6. 8ER RACE 7. <br />MARRIED. NEVER MARRIED, <br />8. DATE OF BIRTH <br />6. AGE (In sm. It UAdw / Yr. <br />(t UttMr u am. <br />Feaal �,hit, <br />WIDO RCED Iet21olU') <br />wi�67 <br />19 -5 -1870 <br />teat ) Me, <br />�}r�°d'F <br />Roam Mla. <br />. USUAL OCCUPATION (Give kind of work <br />10D. HIND OF BUSINESS <br />11. BIRTH- (City, town ar ewep) (titat6 <br />IL Ct17EEN OF WHAT <br />COVNTEYT <br />one during roost of working IIla. awn if mired) <br />H OR INDUSTRY <br />PLACE or toralga OOaA <br />18. FATHER'S NAME <br />1da, MOTHER'S MAIDEN NAME leb. NAME OF HUSBAND OR WIFE <br />Jacob hem <br />Sarah Tritt Adam Large <br />16. WAS DECEASED EVER IN U. 8. ARMED FORCES! <br />16. SOCIAL BECURrrr 17. INFORMANTS NAME or Signature ! Addmq <br />(Yea. no, or unknown (If Sea. giw war or dates of mrvla) <br />NO. <br />Grand <br />no ao <br />ao Nellie Rickard bland <br />18. CAUSE OF DEATH <br />MEDICAL CERTIFICATION <br />Enter only one cauea at <br />line for (q. Ib), and (c) <br />L DISEASE OR CONDITION <br />DIRECTLY LEADING TO DEATH- <br />OmrN W DaatY <br />he not mean the <br />ANTECEDENT CAUSES <br />eA<r>•f�..�. «:7��!� <br />made of dying, utMaX <br />failarq <br />DUE TO (b)r .....r., . <br />��1a4f g ! .. <br />Morbid cendltbna. If ant. glAng � <br />.............����� "/r,�/ <br />• F • � <br />i�heart <br />etc. It means the dia- <br />iw, Warl, or <amvlira- <br />whichcaused death. <br />rtae to the abma caoee (a) stating <br />the underlying cease Wt. DUE TO le)............_.... ...................................................................................... <br />............................... <br />OTHER SIGNIFICANT CONDITIONS <br />relate lone eitease o to the death but °t <br />rooted n the diaew or condition d ath but death. <br />—` <br />19.. DATE OF OPERA- <br />— - - - - -- J <br />19b. MAJOR FINDINGS OF OPERATION <br />20. AUTOPSY? <br />TION <br />Yea 0 No Aj <br />21a. ACCIDENT ..S.wity) 216. PLACE OF INJURY le.g., in r •bout lc. (CITY OR TOWN) (COUNTY) (STATE) <br />SUICIDE home• farm, factory street, office b1da•. etc.) Iif rural • rea, write RURAL) <br />HOMICIDE <br />21e. INJURY OCCURRED <br />21d. TIME FE (Mantb) (Day) IYead (Hour) µ.h11 t Work 121f. HOW DID INJURY OCCUR? <br />e • <br />INJURY �- m. Not WRTI6-ht -Work <br />22. I hereby certify t I attended the deceased Jrom9 v...., 19f.Y to6 /9,7�..rthat I last law the de- <br />...�.,�p......, <br />m the causes and on the date stated above. <br />ceased alive ot%V. 09sf and that death occurredat <br />�..; <br />er��,r H 28c. <br />!/ib <br />DATE SIGNID <br />