|
1. PLACE OF DEATH 2, USUAL. ItESIDk;N CE �W'here deceased lived. If instil d residence
<br />I. STATE b COUNTY
<br />a.
<br />COUNTY before admis•lon ).
<br />Hall Nebraska Hall
<br />b CITY (If oot+;de cort.00a I mit+, it, Rural) �. LENGTH OF c CITY (if t ii arnte write RURAL)
<br />(1Si -_ -.
<br />TOWN Graq_ Island STAY TOR
<br />r. Grano Island ,.
<br />\, d FULL NAME OF (If n ho pilel or 1e +tit ., gill d. STREET (If al, .ve location)
<br />Zy, of � s e[ a'
<br />IlnlrrALDa 11 gdd .) ADDRESS 1017 hest 14 Street
<br />z NSTTU'rlox St. rrallCls osp�ta
<br />:.
<br />3 NAME OF n. IF'ir..c)- - -b. I.Middkl) - c.- .(L."). -.-4. 1 TE._.. (Month) (Day) -_- ,Year)_
<br />ECVASEP
<br />T Prn,t) Mary Weiaenthaler nEATx April 13 19__
<br />5, SEX 6. COLOR or RACE 7. MARRIED. NEVER MARRIED. F. PATE OF BIRTH n. AGE (In yrs.� If Under I Yr If Under 24 He
<br />WIDOWED, DIVORCED ISo,"ify). lastbirthday), Mos. Days Hours Min.
<br />eneae white divorced 7 -30- 1886'' 70
<br />O('('G!1'ATION . kind of wok 11,6. KIND OF BU S[N F'SS 11 town 01 (C ty, to o ro un[y) (State 12. CITIZEN OF WHAT
<br />do dine mo:t fnrkinu I'[n if retired) OR INDUSTRY. PLACE or forerun country) COUNTRY?
<br />Houserife ei i -` _ _ Home ___- ,Howard Co.s_Neb.__. U. ,�,
<br />13. F'ATHER'S NAME � lax. MU1'H ER'S MAIDEN NAME 146 NAME OF HUSBAND OR WIFE
<br />Antone Myers _Mary Novotny John P. Weidenthaler
<br />1, WAS DECEASED F:V ER IN U. S. ARMED FORCES" 16. SOCIAL SECURITY I&j�jJIFt ?QRMAN'T'S A E or Sl aturi &Address
<br />Ye,, no, or unk own (If y v war or dates of rvtce) NO. �', t�liif Ora Ifei en LL ltll
<br />no nos no
<br />Lincoln, NehrL
<br />ska-
<br />CAUSE OF DEATH
<br />Enter only .. 3IEDICAL CERTIFICATION 01 d fietw.tn
<br />' ne caa.c tk.
<br />line for (a), (b), and (c) I DISEASE L CONDITION n•e[ and Death
<br />� DIRECTLY LEADING TO DEATH-
<br />_
<br />-This does not mean the ANTECEDENT CAUSES
<br />mode Of dyin¢, surh .. %
<br />,r heart failure, anthtn{a, Morbid conditions, If anY. ¢ ivin ,D.(16f!Rt�t�t•s"s�irt' /E`�QA .. ...... .......... .....�.]..f.....
<br />etc. It s the dl.- a to the above c e (a) etatln[
<br />an
<br />c eI 1 1 yea d dl th.. th d lyln¢ 1 t DUE TO (c)
<br />ti hi h -.. .... ... _ _ _ ....... ._..
<br />11 OTHER SIGNIFICANT CONDITIONS �V..
<br />! L dt{ • c t e t ¢ to
<br />di death bat n •' (/ f•...
<br />t the dl < o c dition -sous) ¢ de
<br />« l0a RATE OF OPERA Ub MMA�JLO-R FINDINGS OPERATION r 0. A pPSYt
<br />TION
<br />E V 2 Y No JZ
<br />'2I IScecify) 2lh, PLACE OF INJURY ( ¢., In r about ( TY OR TOlYN) (COUNTY) (STATE)
<br />E )F. .home, factory t eat, office bldg., etc.) 0 1 rural re
<br />_ HOMICIDE
<br />1�21d. TIME (Month) (D y) (Year) (Hour) 21e. INJURY OCCUT2ED f. HOW DID INJURY OCCUR?
<br />°c OF C p While at Work a
<br />$ INJURf 1 1 m. Not While at Work q Qtw,-
<br />--- - .IY
<br />g 22 I hereby certify that I attended the deceased from ....., 19.er.3., to.%74111 :.r.-...... 195..7 that I rant saw the de-
<br />ceased atit a on/3 195. and that death o curre_d t� -� �.m., Jrom Ke canes and on the date stated above.
<br />I�23c. IG A URE — _-! / - -Deer r ) 23b. DRESS 280. DATE SIGNED
<br />21 jf 24a. SU AL 24b. DATE 24c. NAME OF CEMETERY A ORY 24d. LOCATION (City, town, or ty). (Sts ) -
<br />�U y)4 -16 -57 Elmwood Cemeterq St. Paul, Nebraska -
<br />e n nR i -
<br />m oll REMOVAL Spe��f ltti suorA�S SIGN R 2 . FUNERAL DIRECT R'$ IGNATURE AD RES$ -
<br />:I� CREMATI
<br />c vin�ston- andermann,Gragc_Ia�aad
<br />Issued April 25, 1957
<br />i .SOS'
<br />
|