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r "- <br />P S- 7981vS, Rea R -,T STATE OF NEBRASKA <br />DEPARTMENT OF PUBLIC HEALTH, DEPARTMENT OF HEALTH <br />EDUCATION AND WELFARE <br />Bureau of Vital Statistics <br />BIRTH NO 126 - CERTIFICATE OF DEATH STATE FILE NO <br />z <br />a <br />C j <br />f <br />i <br />1 <br />1 <br />1O <br />r <br />Ip <br />I« <br />jq <br />I <br />1E <br />E <br />g <br />1 PLACE OF DEATH 2 USUAL RESIDENCE IPA..•da e•.!1•.rd I /,vl•I. R • vv +1 <br />n COUNTY Hall n STATE Nebr DDNTY'" "°gall <br />A. CITY. TOWN.OR LOCATION <br />< LF NGTN OF STAY :N Ih r. CITY. TOWN. OR LOCATION <br />Grand Island. <br />LifeE Grand Island. <br />d. NAME OF II norm InnnyaW. per ernr/ Odd..... d STREET AII u SS <br />HOSPITAL N 124 Se Kimball St 124 S. Kimball St <br />1 SPITAL N <br />r. IS PLACE OF DEATH INSIDE CITY LIMITS, <br />[. IS RESID��EENqNCE INSIDE CITY LIMITS' <br />f.15 RESIDENCE 01 A-�,FARM' <br />YES EA NO ❑ <br />YES 1p NO ❑ <br />YES ❑ NOlJ <br />3 NAME OF Fi- Middle L., <br />4 DATE Al-Oh D., Fear <br />Anna M Bahlpmann <br />DE:TOCt. 31. 1957 <br />pe.,p'ino <br />S SF% <br />6 COLOR OR RACE <br />% MARRIED ❑ NEVER MARRIED <br />GATE OE BIRTH <br />ec. 19. 1878 <br />9 AGE Iln yrnrd <br />f UNDER I YEAR F UNDER IA NUTS. <br />P Wa. N+ <br />Female <br />. White <br />WIDOWED❑ DIVORCED <br />��• i2 <br />101 USUAL OCCUPATION (GI1, kind.l.A,k done <br />IM KIND OF BUSINESS OR INDUSTRY <br />11 BIRTHPLACE (�tilaf[ 1r Jlrnpn rou nfryl <br />12 CITIZEN OE WHAT COUNTRY' <br />eu'inp mon 11 ul.tinv hp, rnn If r[n[ml <br />At Home �:,: <br />At Home <br />Grand Island, i�ebr <br />USA <br />13a. FATHFR S NAME <br />13b. uITIER S MAIDEN NAME 11, E OF HUSBAND OR WIFE <br />xx%xxx <br />Wilhelm Sohipmann <br />Elsabe Voss <br />15 WAS DECEASED EVER IN U 5. ARMED FORCES' <br />16 SOCIAL SECURITY NO <br />17 INFORMANT AddrrAt <br />Y... +�.. o. �,kue,� ill r••. e. •. .n. a d+f.. el u.•.r.:. <br />MA <br />X <br />Helene Sahi mann Grand IslandNebA <br />le CAUSE OF DEATH (EFU only one caws line fi (al, (h), and Irl.� <br />PART I DEATH WAS CAUSED BY <br />'M�'.,' _ I I " / <br />`ryF'�-,- <br />INTERVAL BETWEEN <br />• 1 DFATM <br />IMMEDIATE CAUSE - ('�'_- <br />/ Cihona, IJ °nV, DUE TO <br />e6a[[ pr [u ei4(a 10 <br />°N <br />OOnp the der. DUE TO (r) <br />IVinp anA, !d(. <br />O <br />PART IIr OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO THE MINAL DISEASE CONDITION IYEN IN PART 100 <br />WAS AUTM <br />PERFORMED' <br />YES ❑ NO <br />201 ACCIDENT SUICIDE HOMICIDE <br />206 DESCRIBE HOW INJURY OCCURRED (F.'nrrr 1- 1110111111 in PIFf 101 I'll? 1111i". Is) <br />u� <br />❑ ❑ ❑ <br />u <br />20C TIME of f lour .HontA, OAF. Year <br />G <br />INJURY <br />P. m. <br />f <br />20d INJURY OCCURRED <br />2De. PLACE OF INJURY (e. p., In Or ahouf homr. <br />201. CITY. TOWN. OR LOCATION COUNTY STATE <br />WHILE AT ❑ NOT WHILE <br />WORN AT WORN <br />/arm, /arfarY. Al"n, office body., efr.) <br />21 l attended the deeeeeed from �f to �� s end lase sew .live on <br />__ <br />D th occurred at On the date At.t and to the bet Of my An,.Iad lrom the uue a Rl.ted <br />22e. GNATYIK (1Xpree or title) _ <br />/yam•_ <br />DRE55 22e. DATE SIGNED <br />�� !' <br />� ?'rlsA -�O Y <br />.� <br />ly 23, �BURIAL. CREMATION 236 ^ <br />go .r.T[ <br />_Dlir�(all /F1 j /t( ;r, <br />I .1 r "✓r . T <br />j 24. DOE RECD. BY �;GIS'RA• I2S. P <br />N V .")t -c <br />5 ! 1 <br />X93 <br />