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{ <br />1. sCO' <br />LACE OF DEATH 2. URUALNET.SIDENCE jWhere ijeeased hued. If institution: rmid.noe <br />a. STATE Nebr. b• cOuNTYHall before admission). <br />a. COUNTY <br />�' -- - Hall _ -- — _ <br />- - -- <br />.'�1 b. CIOR (It outside <br />corporate limits, write Rural) SLAY N G T H OF c. CITY (It oruttsfdaendrlwr�elima+n its RURAL) <br />TOWN _brand 'Island Ic TOWN br 1 11 Q� — <br />i ^� �d. FULL NAME OF (If not in hospital o institution, eivadd� 8et d. DRESS 215 East t 14th tlon) <br />o HOSPITAL OR r <br />x �_ INSTITUTION 215 East _114th_ 9t — - - -- <br />_ NAME OF e. (First) b (Mlddl) c. (Laetj d. DATE (Month) (Day) iYear) <br />g nlclwsED L Tillman _ _ DEATH DeC.24. l`JSg <br />John <br />.1 5. SEX 16. COLOR or RACE T. MARRIED NEVER MARRIED. 9. DATE OF BIRTH 9. AGE (In yr.. If <br />Under 1 Yr. if Under 24 Hrs. <br />WIDO ED DIVORCED (Specify) last birthday) Moe. Day. Hours Min. <br />,isle —'I White ldarr�ed Jana t3. 18 5. o <br />10 USUAL OCCUPATION (Give kind of k 106. EIND <br />OF R INDUSTRY 11 PLACE (City to fore(6(� quaytq() Late 12 COUZEhITBYT SAT' <br />n during moat f orkine 1{te, even if retired) Hi htlan�vlYYe e Mloa U.`iK <br />ICI i l ark/ �HZl 14a. MOTHER'S MAIDEN NAME 14b. NAME OF HUSBAND OR WIFE <br />13, FATHER'S NAME <br />Henry Tillman- Fancy Landers Brosia Tillman <br />G$ l6. WAS DECEASED EVER IN U. S ARMED FORCESY 16. SOCIAL SECURITY 17 INFORMANT'S NAME or Signature & Address <br />.5,.\13 (Y no, or unkn`91f Yee, Hive ,,rrH -- --- <br />dates f lY' Brosia. Tillman brand <br />_ re <br />'13 is CAUSE OF DEATH MEDICAL CERTIFICATION a neat and Death <br />only a cause Des L DISEASE OR CONDITION <br />= q Erse [or ( <br />I. (b), and (c)i DIRECTLY LEADING TO DEATH' n <br />x a).......Ctc%h yatd� t.1 ....... ... ......3c.. <br />_- <br />u 'This don net .ucn the ANTECEDENT CAUSES DUE TO (b).... . <br />.... .... ..i, iii..... BITS... .....'�.<.S'Ge.........UzLU�tur .I <br />sfd S II <br />�mv �' ode of dyin[. <br />��heat failure, asthenia,; Morbid conditions, If anY. g {vin[ <br />p,< ate. It means the die-'I rise to the above can (a) etaUn[ <br />Oo 'see. Injury. or nmpliea- the nnderlyin[ cause Wt. DUE TO ( c)_......_ ............ ... ... ............... ....._..._.........._.......... _. ..................... .......................__...... <br />tlon which caused dea�L -- - - - - -- -' - - -_ -- - -- <br />V >, II OTHER SIGNIFICANT CONDITIONS <br />Conditions ront,ib..n. to the death but not - -- <br />�t i elated to the die se or condition {n[ death. T2 <br />M _ -OPERA . —_. -. _de ...___ _.. ..111.1 _.— __.... —__ 20. AUTOPSY' <br />�p 19a. DATE OF TION 19b. MAJOR FINDINGS OF OPERATION <br />,F <br />� Yee <br />__ '_'_ <br />a 21a. ACCIDENT (Sp 7216. PLACE OF INJURY ( r bo t ]c. (CITY OR TOWN) (COUNTY) (STATE) <br />SUICIDE h me, farm. fsetory, street ft bldg. t l][ el area rite RURAL) <br />HOMICIDE_ 23e. INJURY OCCURRED <br />�— 21t. HOW DID INJURY OCCUR? <br />9 ltd. TIME (Month) (Day) (Year) (Hour) While at Work <br />m J m. Not While et Work <br />S INJURY r-l� <br />I: 2x.1 hereby certify that I attended the deceased from.... r/.'..f.tf...., 19x./.53, to..... /. z.' , 19.i7f.., that I last Sato the de- <br />jpi4. f <br />ceased al{v n.....y,.'�.3, 1957►,--- a7n��d�th�at death occurred at .....m., from the causes and on the date stated above. <br />28a. SIGNAT Degree or t(tle) 23 DRESS 28c. DATE SIGNED <br />g _ yW. RJl -mod � /Z -b8•JZ <br />24a. BURIAL j�( 246. DATE Y4c. NAME OF CEMETERY OR CREMATORY 24d. LOCATION (City, town, or eonnty) (State) <br />CREMATION p Dec.27,(5rand Island Cemete rand. Island[ Nebr <br />s REMOVAL ❑(SiecifY) _ <br />DATE RECD BY IACAIT R�� PF ,SIC1 UN DI ORB SIGNAT DR <br />Issued January 29, 1957 <br />`O/ <br />