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■ <br />y <br />PHS- 79s(VB) REV. alas STATE OF NEBRASKA <br />FEDERAL AGENCY <br />9ECURfM t DEPARTMENT' OF HEALTH r <br />PUBLIC HEALTH SERVICE 2 2894 <br />EIBfbe Nan srawnos ,� <br />BIRTH NO. 126_____ CERTIFICATE OF DEATH SPATE FILE NO. <br />1. !'LACE OF DEATH <br />s. USUAL REBIDENCE (Whaes dmwad B.ai H in.titvnuv: eetdd�w <br />i <br />a. COUNTY Hall � <br />(" <br />'11�� b, fQ,ENT'Y before adalMlm). <br />a CITY (H mtdde OmVOrale limltI6 write RURAL) <br />b. CITY (If o�Wda lorlmrato Bantle, write Ramp <br />a L E N G T 8 O <br />_TOWN W011H ,yer rural J <br />IsTAY (in thin Dines) <br />TOWN WoodRiver <br />i d. FULL NAME OF (It not in boaDiMl 01 institution, give street schi am <br />d. STRRET (H rsral, Siva kmunn) <br />z INSIITUTION At Farm Home or leeaHon) <br />ADDRESS <br />9, NAME OF (Fire) b. (Middle) a. (Lad) <br />nECEABED Gilmore l'i188men <br />l e, oi+� (Mmth) (Dar) a'e`1 <br />a (Tres or Print) Re <br />DEATH Marc h2 7,19 5z <br />S. SEX <br />g. COLOR or $A <br />7. WMIARRIED, NEVER MARRI$p !. DATE OF BIRTH <br />9. Ap��(,rftn�,j��y H Under 1 Yr. <br />I.0 )lit <br />Des. <br />H Under 4e Kea <br />H—I Mm <br />Male <br />Whit <br />i�ao�IieljoRCED18DmIf,>I $�14�1878I <br />to I <br />I <br />Igo, USUAL OCCUPATION (Give kind of work 10b. KIND OF BUSIN Ile (City, tawny" oo•m•yt7y) (State <br />done dnaj;,Kg�te.Vorking Bfq oven H retlnd4gr,0UlOjS �Ryj1 <br />lE CTITTZEN OF WHAT <br />pBIyRAT�H- <br />Qj jetow�,,I+' 'a *T')d <br />1ZAM�E <br />UO S 0. <br />13. FATrrH22E1R1l'Sf7l1N <br />NAME OF HUSBAND OR WIFE <br />14- MOTHER'S MAIDEN NAME II <br />�H► <br />Yartin Z. Wiseman I Martha Ray. {8gust8 Whittler, <br />I5. WAS DECEASED EVER IN U. S ARMED FORCES? 16. SOCIAL SECURITY <br />17. INFORMANT'S NAME ee Sisnawn, A Addrass <br />(Yee. vo, or onknown)I(If yea, sine war or dates of rrvio) no o NO]Warvin <br />Wiseman rfoodRivetw9hr <br />11, CAUSE OF DEATH <br />MEDICAL CERTIFICATION <br />Interval Bate <br />Enter Duly one ranee ttr <br />line [or (a)' lb), and (e) <br />I DISEASE OR CONDITION ' <br />DIRECTLY LEADING TO DEATH• <br />Onset a Matt <br />and <br />�iyed4. <br />— <br />(a)._ ...................._._. __... o........ ._.....__.._......_............ ......._...._........ <br />•Thle doe. not moan Ha <br />mode of dying, such u <br />ANTECEDENT CAUSES ' <br />DUE TO (b). _.__....... ._.........__..._... .. ..._....._............ <br />. ............. . <br />... <br />heart (Ware, sthenia <br />• <br />e. It means the die- <br />con an <br />Maf id ditions. it y, gyms <br />riw b the aMn uum (a) s4lhts <br />'I,e, INeh or cd d-t ' <br />\, Oen which uvaed dwt►. <br />tk andertyins wow Wt. UUE TO le)...__.. ........ ................. .._.._. <br />11. OTHER SIGNIFICANT CONDITIONS <br />Godill— unlrDatlns to the death but not <br />eehled to the di,e— er oandilion uusins death. <br />19a. DATE OF OPERA -I <br />TION <br />196. MAJOR FINDINGS OF OPERATION Ise, <br />AUTOPSY? <br />Yw 0 No <br />:tae ACCIDENT 191xrJb) rib. PWCE OF INJURY (e.s., in about <br />sle. (CITY OR TOWN) (COUNTY) (STATE) <br />SUICIDE home, farm, Letory, atreet, offlu bkts.. ate.) <br />HOMICIDE <br />(It rural area, write RURAL) <br />21d. TIME (Mouth) (Day) (Year) (a_)I kla INJURY OCCURR <br />Jlt. HOW DID INJURY OCCUR? <br />OF While at Work <br />INJURY Not While at Wwk <br />zz./ )tereby certify#h/a L 1 attended the deceased Jrovt..... ...7........., 19.5x' to..._... .7......., 19S.t, that I last saw the do- <br />ce lice on. and that deafh occurred at..lQ._)�m. ,ftrom_j a causes and on the date stated above. <br />f <br />