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6-Af <br />a- STATE OF NEEAASKA <br />PUBLIC EALTH, DEPART TH PHS -s Wba -004036 • <br />OE S 6 £DUAT N N ureaM o r. <br />BIRTH NO. 126........ CERTIFICATE OF DEATH -STATE- FILE No...... ....._ ......... _...__ ....... <br />�__ <br />_ - -__ _ <br />1 PLACB OF DBATN � A "C- FIW��•e���� t- nub —t orlon: -- aer«wen <br />COUNTY Hall SKATE Nebr. s COUNTY hallbefO1e'd0lmdon)• <br />- - - - -- - - --- - - - - -- <br />r. <br />CITY (It outside corporate Ilmta, write Rural) STAY N G T a OF e. CPOlt (II outride m per to 1{mte.. write RURAL) <br />OR <br />d. FULL NAME OF lit not in hospital or imthutlun, give Kohn d. STREET (If rural. Five location) <br />HOSPITAL OR address) ADDR£98 lls9_. SO California <br />INSTITUTION_ -- -- <br />9. NAME OF a. (fleet) b. IMldd'1e) - "— a (I.aM) 1d. DATE (Month) (Day) (Year) <br />nECEAS£U <br />(Ty�wPrnt) _ Verna _Aar. a Wallace, DEATH -_pril 2, 1956 <br />s. SEX le. COLOR or RACE�WIDO ED NEVER ED (Swci, TB DAY£ OF B11iTH i a. AGE: it. M. I Der. !Neu KID. <br />WIDOWED. DIVORCED (Bps itY) <br />emal a Nhito�_�__YSr�i€sl.___. __ __�2T�2 --915 . _ _!_ - -. OF tea. USUAL OCCUPATION (Give kind of work.10b. HIND OR INDUSTRYI 11 PLACE (City or foreign -try) Vta IP COU RYt WIiAT <br />lone during most of working Ilfe. even it retired) _ U -A Nohr_ de A. <br />t. - - - -_. _ ---- <br />13. FATHER'S NAME Id.. MOTHER'S MAIDEN NAM <br />& 1°b. NAME O <br />_ _ _ enn.a- �SShaw No. Curti. @__L. _D,_ Pfelleeg.___ <br />�Arthur_.1Alk* --- ' - <br />16. WAS DECEASED EVER IN U. S. ARMED FORCES'. 16. SOCIAL SECURITY 117. INFORMANTS NAME or Signature ! Addrem <br />Y Curtis C F'allace <br />no, unknown (If yes, give wee or date of °ervke). -. -_- <br />- _.. - <br />n __. <br />CAL CLRIFICAT Be <br />t <br />le. CAUSE OF EDI <br />,Oewt and Death <br />Enter only one i DISEASE UR CONDITION <br />\ Ilne for (.), (b). DIRECTLY LF1DING TO DFATH• <br />cause pe <br />sad /c)''. I. .ggfeeLrM.a�fx. -. .. ....... /�!..w.rt_........ <br />•This don net mean the''. ANTECEDENT CAUSES DUE TO (b) ............... ............ _. .. ......... _.. _............. .......... <br />ads of dying, inch <br />heart failure, thenla,', Morbid odItI nr, If Y, giving <br />u ca an <br />etc. It mean: the Sir riw to the above nue (a) stern[ <br />sue. which or ed de h. the ..4-1 . ri g r...e Wt. DUE TO Ir) <br />tlon whl h cured de th _. _. ._ <br />II OTIIFR St( NIF [CANT CONDITIONS <br />E, ,y'} X � Condill tribvti [ net - <br />f / elated t tb dl:eu or condition au° n[ death• <br />20. AUTOPSY' <br />19e, HATE OF OPTRA 19b. MAJOR FINDINGS OF OPERATION <br />ION Ye. N1 No 0 <br />-- n or b t _'1c. (('ITY OR TOWN) - (COUNTY) (STATE) - <br />_'lx ACl [DF,NT (SPe t!y) 216 PLACE (1} INJURY 1 If r.l sees rte RCD�QLIpp <br />SUICIDE ,,/// If 61dg t .)M�'LaL`L, <br />HOMICII)E/p r <br />1. INJ1. RY OCCURRED 'if. HOW DID I \JURY OCCUR! <br />'21d. TIME iMonth) ID.Y) - IY—) (Ha ) K'hile at Work <br />OF m. - Not While <br />INJURY PU'e%1 9SIi,. O,'OG <br />/�/'"''"'vv rlast Bata the de- <br />s_. I hereby certify that I the <br />Ccaard etitr an.�..., l9.if..., and that death of utrrcd atAJ °A. ,, -nt /ru>n t-1he cauac.v and on the date state above. <br />r tlkxrvc tile) 226. ADI RESS (4....,r21 DATE <br />23., NNTURE ¢�L�� uFceMe: <br />24.. BURIAL �- 2tb. DATE -'a H TEILY OR CREMATOR 21d. LOCATION �fity. tow or county) (3tet<) <br />CREMATION <br />REMOV L ❑ sG" HY) 4 -4 -56 ,ES ;lawn dlem+orial park Gr.tn.d ZsLL.rd, Nebr -. - - -- <br />D� E('fl'HYI yI(v[ RFG:I (,�F. FUNEItAI IIItEGTORb SIGNATERE ADDRESS <br />Mr +IY�tti2fTF I>� y <br />- Sonder- mann u -r- and Islend <br />EtonI in <br />- <br />Issued May 16, 1957 <br />