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PHS- 798(VS) REV. 7 -53
<br />DEPARTMENT OF PUBLIC HEALTH,
<br />EDUCATION AND WELFARE
<br />BIRTH NO. 126 --------
<br />1. PLACE OF DEATH
<br />a. COUNTY Hall
<br />Cop�ie
<br />STATE OF N RAS
<br />DEPARTMENT OF HEAL n B
<br />Bureau of Vital Statistics
<br />CERTIFICATE OF DEATH STATE FILE NO......
<br />vovn,_
<br />I a. STATE
<br />(Where deceased lived. It institution: residence
<br />b. COUNTY Hal ]before admission).
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<br />b. CITY (If outside corporate limits, write Rural) c. LENGTH OF �!. c. CITY (If outside corporate limits, write RURAL)
<br />d Co OR STAY. OR
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<br />YS a TOWN Grand Island 1 day Towx 1�nni} -� •a -1
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<br />d. FULL NAME OF (If not in hospital or institution, give street', d. STREET (If rural, give location)
<br />oil HOSPITAL OR Y _ address) I. ADDRESS
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<br />OF a. (First) b.
<br />AType or Print)
<br />5. SEX 6. COLOR or RACE 7. MARRIED. NEVER MMARRIED, 3. DATE
<br />VDOWED, DIVORCED (Specify)
<br />-_ -- A rri'rl A.11m)
<br />4. DATE (Month)
<br />OF
<br />DEATH March
<br />BIRTH 9. AGE (In yrs.', If Under 1 Yr
<br />3_ 1
<br />lastbirtJclgy)j y) �(ps. Its
<br />(Day) (Year)
<br />4. 1957
<br />If Under 24 Hrs.
<br />Hours Min.
<br />10a. USUAL OCCUPA I h (Give kind of work 10b. KIND OF BUSINESS'II. - BIRTH- (City, town or county) (State:12. CITIZEN OF WHAT
<br />„ ne in mpst f worki g life, van if retir d)- pR INDUSTRY PLACE or foreign country) CQ.U�IRY7
<br />e� rgea Fi:ere�i�n eneratl tt�dar, Store -. Hall County, j�ebr Ujjj�3 _
<br />13. FATHER'S NAME NAME 14b. NAME OF HUSBAND OR WIFE
<br />:' wiW SiDEICEASED Bu I �U. S. ARME1rFORCES? a A16 SOCCreaCL' n 17. I Cln.rlbel Bur�TPr
<br />15. INFORMANT'S NAME or Signature & Address
<br />(Yes, tiW�or unknown' (It yes, Ri +e war or dates of "r ,ice) h0. -
<br />11 508 -18 -7571 Claribel Burger Dons r.n
<br />18. CA SEU OF DEATH' MEDICAL CERTIFICATION F C pterval Between
<br />Enter only one cause Pet I. DISEASE OR CONDITIOS Onset and Death
<br />DIRECTLY LEADING TO DEATH•
<br />line for (a), (b). -and (c) (a). Art. er. �. .f),II.C.1.C.r0.t.'�.C._.}1C.3.I , ti..... dj,$ l ;�si.m .......................
<br />*This does not mean the ....._.... _.. ...__ ... .. ..... .............
<br />DUE TO lb)... .. ... .................._.......
<br />1NTFCFDENT CAUSES
<br />mode of dying, each as.
<br />heart failure, asthenia, Morbid conditions, if any, giving
<br />etc. It means the dis- rise to the above cause (a) stating
<br />ease, injury, or complica -. the underlying cause last. DUE TO W -- --
<br />tion which caused death.'.. - - -
<br />II. OTHER SIG_vIFICANT CONDITIONS
<br />py Conditions contributing to the death but not
<br />related to the disease or condition causing death
<br />19a. DATE OF OPERA- 19b. 'MAJOR FINDINGS OF OPERATION 20. AUTOPSY?
<br />TI ON
<br />I Yea EJ No
<br />21a. ACCIDENT (Specify) '21 b. PLACE OF JURY >„ in r bout 21c. (CITY OR TOWN) (COUNTY) (STATE)
<br />SUICIDE .home, farm, factory, street, office bldg., etc.) (It rural area, write RURAL)
<br />'. HOMICIDE -- - - -- - - -- -
<br />�- (Year) (Hour) '21e. INJURY OCCU F2RED 'If. HOW DID INJURY OCCUR?
<br />(� 21d. TIME (Month) (Day) ( While at Work
<br />OF
<br />INJURY n'' Not Wh I , at Wo. k
<br />22. I hereby certify that I attended the deceased front .. ..... 19 .. to..... ...... 19......... that I last saw the de-
<br />ceased alive on.... .....1 19 .... and that death occurred at . m from the causes and on the date stated above.
<br />23a.- - -- _- 23 ,BATE Iffy W,
<br />23a SIGNATURE (I1eRree or title) 236. ADDRESS c 1 +�,rC� O/ t
<br />H C. An ? e r n LrD. car' c' S-�1_
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<br />24a. BURIAL ! 296. DATE 24c. LnME OF CEMETERY O C�i.EIs1. E 'O'Ch1'fON (City, town, or county) (State)
<br />z CREMATION pp 1 -r
<br />o, REMOVAL (❑SpecifA rCi1 7 • 195 i Ce`dar View Cem_ eter,.% ontph;;,n, Idebr
<br />i' - -- - -- -- T -- - - -- - -FU E A1, DIR .TOR'S SIG RE ADD
<br />DATE RECD BY LOCAL REGISTRAR'S SIGNATURE
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