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w <br />I <br />i <br />A <br />I <br />I <br />f PH&! Ve REV. 1 -68 TATD OF N...A'M <br />EPUA <br />Cr Aff WVAC RHLTH. <br />-A tj0 gbh <br />II S <br />1. 01027,1 <br />BIRTH No. 128........ CERTIFICATE OF DEATH STATE Ftta1:5 .................... <br />. PLACE OF TH <br />a <br />r lived. nt t rplNnp <br />COUNTY is 11 <br />Z _ U_GSo' <br />\! b. CITY U! telde oorpo to Ilmlo. welts Rev.]) L E N O T H OF <br />T TOWN Grand to ;TAY <br />a. STATE h. COUNTY beforo edmlayn). <br />Nebraska Half <br />u. CITY III ouolda eorporn4 Ihdo. Arlo RURAL) <br />TOWN <br />d. FULL NAME OF (I} of In hnpit(tl or tnetltutlon, give dreet <br />d. STREET (I} rural, give "radon) <br />z INSTITUTION Lutheran xospital wa.«.) <br />ADDS 904 North Y7heeler <br />i 6. NAME OF a wirer) b. (Middle) 0 (L1 <br />DECEASED <br />d. DATE (Month) IDw) (Year) <br />a. Print) MBrj' Dohrn <br />DEATH OCt. 70, <br />5. SEE 6. COLOR or RACE <br />7, MARRIED, HEY MARRIED, <br />8. DATE OF BIRTH <br />g. ACB (Iv yn. <br />[} Under 1 Yr. <br />_175$_ <br />if UMSr 26 Hn. <br />Felnalej white <br />WIDOWED, DIVORCED (Specify) <br />widowed <br />10-23-18701 <br />Wt bit. day) <br />85 <br />Moe, Dayr <br />Houn Min. <br />USUAL OCCUPATION (Give kind of work 106. RIND OF BUSINESS Il. BIRTH- (City, town or owvtY) Btno <br />done durin o! working 11 }e: even 1} rodr%) OR INDUSTRY " PLACE ar foroon country <br />12'. CITIZEN OF WHAT <br />COUNTRY? <br />Hevoet ,, <br />1i <br />19. FATHER'S NAME` ua. MOTHER'S. MAIDEN 'NAME <br />16E, NAME OP HUSBAND OR WIFE_ <br />Frederick "eldt Henrietta Eickoff <br />John Dotirn' <br />16. WAS DECEASED EVER IN U. 8. ARMED FORCES? 16. SOCIAL SECURITY 17. INFORMANT'S NAME or. 8lrttatont • Addren <br />(Yn, no, Or unknownl(I} yn, rlw wv or darn of wrvice) NO. <br />no no I no Alma_ Scov311,Grand Island <br />18. CAUSE OF DEATH MEDICAL CESTOWATION (n [wren <br />Enter only one enure (.1 t DI�gL, OR [OH •- OAS <br />Ilne for (e), (b), and (c) <br />DIRECTLY LEADING TO DEATH• <br />LEADING <br />•e - d d' not mean iha ANTECEDENT CAUSES <br />made s1 IR" eavh u DUE TO (b).. t!( .6Sr.6•g�.... <br />►earl fallen, uthmo. Morbid nndltlene, il. <br />any, thin[ <br />eta It meant IM dlo• Itn to the ebo a n•m (a) Morin[ <br />i0 oty. er romPlira- the ''ro <br />erbinr new WL DUE TO (c).. _...... <br />tbn welch nueed dnN <br />II. OTHER SIGNIFICANT CONDITIONS <br />Qr l Cendttlene he die- U'. o the a.ath ht nn <br />[•rated to the dlmw'or Andiron ouelnr dwW <br />/t�ia <br />19a DATE OF OPTIOAN 9b, MAJOR FINDINGS OF OPERATION. 29 AUTOP3Yt <br />I� l <br />Y_❑ No <br />_ <br />11, ACCIDENT (�Sp�e� /{ty) 2ib. PLACE OF INJURY le.a. i bout 1 (CITY OR TOWN) (COUNTY) (STATE <br />HONKDE �h }ar facto y t t oHi c bid tell 111 r e r wrl RURAL) <br />21d. TIME (MOntA) (DMy)(Yar) (Hour)w,h UR Ok CURAED1 ,HOW /DID INJURY OCCL'Rt /f <br />t /Oss�A <br />INJURY g m., Na While t W k� <br />_ <br />2z.! ereby certify t I attended the deceased from.... .. 7 , tolXlrT..t,lo...., 19.x?.., that I k t saw the de- <br />�� c ed et" a on JO., 1 eBi{�- and that death occurred at / m., from a a on the_date stated above. <br />26 IGN TU E AD 29 DATE 8[CNED <br />IAME 44d.LOCATION <br />_SS"T Y <br />tea B IAL O ETE3 ICir <br />a y, (B.te, <br />2ib.(: F <br />1row <br />CREMATION C 4 .• <br />Grfl <br />1 <br />� I REMOVAL � _S—It) - <br />e I <br />AD TE REC'D tlY •.UCAL' :F.G Ij6: 3 5. g{INFRAL- [>(RECTO S SIGNATURE ADD -� _ -- <br />ll e <br />r <br />.,16% <br />