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6oS <br />0. Blrtbvlsca _._.Ii1.e.1...,.._.._..__...._ _.i I many. +_ —__._ (In-Inds nay wf. is i meatm of death) PH1(fRCIAN <br />(City, toy�n, or <—ot) (State or foreign oosntn) <br />10. Uasal occupation— t10 u S e Pi f e e Major dndlHp: <br />— .�._______ —. IIMaellas <br />It. Indsetry or buslneu...20LmP... _......._.__..— __.__-- .__ -.»._. Of the emse to <br />whkb dearth <br />- -. 11101+4 <br />step. y............__.__.........--..._.. .......- _..._ .................. <br />f;8 a 8. BirthDiace�j{(��.... OOT.d. ._......_ ... /��i'p,.ula r� .._..._._ .. .... t4Hmlls. <br />iy (City, n. or eon�ty) (draw er rcre "7Rn �nn4y) <br />@ � u. Maiden .Dl a_ -FCtac o-rrd — - - -- - — -- - -- - <br />Hems......._ <br />� y_.......�._._.__.__._ —_. 22. It death wu due te ezternal casxe, sU is the fallowingt <br />�w14. t� o fo�plQn aoantn) (a) Aeeldeat, suicide. or bomletd. <br />or rnn ' A <br />u, 10. (a) Informant's own etsnat Si. +pN* - (b) Date of occurrence..- ----- <br />_- ._.___. .._�. <br />L <br />,e (b) Addren....— ..— ..-- _._...__ (e) Whom did fain" Decor t._...._......_.._.— ...__ —.___ <br />:$ 17. fa)...... B11T.1..a1......_._. (b) Date tinreo'...___.E./C (City or town) (County) (Sba'S <br />(Burial, erometion, or removal) (Month) (Da'AL (d) Did In1nn occur In or about home. on term. In Industrial Dfam, In <br />g (c) Piece: burial or eremaitfQT_anA__l.alS anr3 ltd g]>x- - patine Dtaee7...._............_ .�__.�_...._.._.— ...._.... —_—._ ...... <br />18. (a) Signature of foaeral T6;LV4.n.B-p1-on -SOAde 98n (8peeify type of plum) <br />y T Willis at work T_......_- _:_.._ —_ (a) M of _- <br />(b) Add ress ...._____.___.— �.i.��.�1. ��, " "" " "" " " "��.���,,, y� <br />�.1 r 22. 8lgnatare. ..... <br />r/.l�tl.It4 . (M.D. <br />fDat6livedl I" "si3trv)� (b) (Retstrar'e elgH�tetn) Addteu..... .... _. OW al <br />Issued July 16, 1957 <br />NEBRASKA (STATE) DEPASTMXNT O <br />OF ffiALTH <br />! - <br />- Mbion of Vital S <br />StatLNae <br />V B <br />STANDARD CERTIFICATE O <br />OF DEATH <br />Lz ( <br />I. PLACE OF DEATHi Z <br />Z. USUAL RESIDENCX OF DEGAS ®t <br />I�. 1 <br />. q <br />__...... _..- .$..ti.......E'.r.ann {8.... .0gn. .. .8.1. »....._.._._..__...._._.._ ( <br />(d) &ratNa...2. ._.Y.�.�._:�.� V. n4 GrAnd 2w�AUA, p <br />q¢ ( <br />MEDICAL CERTIFICATION <br />- -- J <br />8(b) If voteram 2 <br />i.8r2._.Rzue$.Sr wife It <br />7. Birth date of dcaeased ... _...... D <br />Daa a._...___._..___........»...... -------- <br />_._..�.._.........._..... • <br />•..,_..._ i <br />S. ACE: Years I <br />Months I <br />H lass than om day D <br />Dus <br />� o <br />88 9 <br />I M <br />oeb.e mndittona. _. <br />Issued July 16, 1957 <br />