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-- eQaao.tet uas <br />life. It md"d) arR <br />serU an <br />IS. .FATHER'S. NAME 14. MOTHER'S MAIDEN NAME Idb NAME OF HIISBAND -OR wETs <br />H. Sunderaaier r. Anna Schroeder reida Lena - O Brae r <br />1L WAS'DECEASED EVER IN U. S A8M8D 1t1HCEST !t. EOCIAL BECUBIIS IT., INFORMANTS NAME ar _8Wm@1d . (k AA&W <br />mk.o (If s.,. dw w.r ur dde. of aria) _ NO' <br />no 1.1t.8ul►derEteier,Grand ,I <br />- IIO - - - <br />lb: - 'CADGE OF DEATH � MEDICAL Ali <br />H- I Qtly ow nar. Da L DISEASE OR CONDITION <br />Ns tar (a). (b), aad (e) DIRECTLY LEADING TO DEATH' <br />'Sfb Mr M <br />dt aru tb. ANTECEDENT CAUSES <br />is.�.. D . 70, <br />NSA" asdlti.tu6 a aw. BMW <br />t , .r waBrr � M lb. WbM rant. (A) .UtbW <. <br />d -wblei ewM tlalb triarblas taw -kwL DUE - To - (a)� _ - <br />' a. OTHER ZGNIFICAMT .OoMv IONS <br />P C"tkw ashlMtba *Ater; dat► bat wt r: <br />4 r.LW N W db— — .00th. wstbut dad\ <br />3 I9k: DATE OF Opm, 19b MAJOR FMINGH OF,orEEATIOtt: Nt <br />21 . ACCIDENT (HDrdy) <br />Sib. Ff.A/S OF HtJIIM N. to ar *teat sie (CITE OR 1'OwN) Wi1tF33) /!1!ti <br />12=D11E b—. f4m tatdq, -..k au b11d.. (M�ia.. sr "!4 = ] <br />no <br />ft Rt <br />Sid. T� (Me A) (Dw) (T.or) (Haar) wtaH. st wak •�,�. sv. NOW OCCURS INJURY <br />� » tt, t LdTObtl CM 9 IV I mdo me l d� r • AD.. ,l (f• ^`E '�! <br />cco.sa ttltoe oR: , 1 ,.Edtlat �tlt occMrTilae. 1�*a t 4w++b.Ha�oa <br />m SIGNATDae <br />vwAA !db DATE tddE. ' OB m <br />"` ECRx",a`� P.17 3iplr PMf3l�t� <br />i•'.wL.!� nttr�n af[. "LOCw-- TR[7Kwt +Z7 tf. _EtlltEtA4_D <br />r( <br />V <br />t' 9 <br />n% <br />V , <br />fr <br />i <br />PHS- 798(VS) REV. 7-63 STATE OF NEBRASKA <br />DEPARTMENT OF PUBLIC HEALTH. DEPARTMENT OF HEALTH <br />EDUCATION AND WELFARE Bureau of Vita) Statistics <br />BIRTH No. 126 -------- CERTIFICATE OF DEATH. S <br />STATE FILE NG...._. -_.... <br />( U <br />UZATM . <br />L I.ddNa <br />._ -... ... _ - 2 <br />_ <br />% . <br />b. CTTY (If wtside . t Hmtt.. writ Rural) S <br />STAY N G T H OF a <br />a -C O "(If wbide eorponb iid4, write RURAL),' <br />ro °wx Grand aland T <br />TOWN Rrl <br />N. d <br />d. FULL NAVE OF (If as la bapdtal a m.timeba, dva dre.t d <br />d. STREET - - <br />- (If rd. d.. barks) <br />HOSVPrTTTlrio °NR St. Francis Hospitnl'd °) A <br />ADDBESSlO Elie S <br />SsE.Grand *land, . <br />F6 h ( k) a Etast I <br />I. D <br />Ei. D <br />Dw F <br />DDOF p <br />S. SEE <br />S. COLOR or RACE 7. MABRDID. NEVER MARRIED. B. DATE OF BIRTH 0. AGE(IS 7rr. H <br />H IIaddr t T1', IIsb�ft $rw;- <br />.- exv.rrs�Trnx (GI.. ktea:.d .mrk l.b.'ERID OF BUSINESS Ill. BIRTH -. (City, toms ar .emtt) ( <br />(80L It:.CF[I$l6Ei- _Of.ftAt'- <br />life. It md"d) arR <br />serU an <br />IS. .FATHER'S. NAME 14. MOTHER'S MAIDEN NAME Idb NAME OF HIISBAND -OR wETs <br />H. Sunderaaier r. Anna Schroeder reida Lena - O Brae r <br />1L WAS'DECEASED EVER IN U. S A8M8D 1t1HCEST !t. EOCIAL BECUBIIS IT., INFORMANTS NAME ar _8Wm@1d . (k AA&W <br />mk.o (If s.,. dw w.r ur dde. of aria) _ NO' <br />no 1.1t.8ul►derEteier,Grand ,I <br />- IIO - - - <br />lb: - 'CADGE OF DEATH � MEDICAL Ali <br />H- I Qtly ow nar. Da L DISEASE OR CONDITION <br />Ns tar (a). (b), aad (e) DIRECTLY LEADING TO DEATH' <br />'Sfb Mr M <br />dt aru tb. ANTECEDENT CAUSES <br />is.�.. D . 70, <br />NSA" asdlti.tu6 a aw. BMW <br />t , .r waBrr � M lb. WbM rant. (A) .UtbW <. <br />d -wblei ewM tlalb triarblas taw -kwL DUE - To - (a)� _ - <br />' a. OTHER ZGNIFICAMT .OoMv IONS <br />P C"tkw ashlMtba *Ater; dat► bat wt r: <br />4 r.LW N W db— — .00th. wstbut dad\ <br />3 I9k: DATE OF Opm, 19b MAJOR FMINGH OF,orEEATIOtt: Nt <br />21 . ACCIDENT (HDrdy) <br />Sib. Ff.A/S OF HtJIIM N. to ar *teat sie (CITE OR 1'OwN) Wi1tF33) /!1!ti <br />12=D11E b—. f4m tatdq, -..k au b11d.. (M�ia.. sr "!4 = ] <br />no <br />ft Rt <br />Sid. T� (Me A) (Dw) (T.or) (Haar) wtaH. st wak •�,�. sv. NOW OCCURS INJURY <br />� » tt, t LdTObtl CM 9 IV I mdo me l d� r • AD.. ,l (f• ^`E '�! <br />cco.sa ttltoe oR: , 1 ,.Edtlat �tlt occMrTilae. 1�*a t 4w++b.Ha�oa <br />m SIGNATDae <br />vwAA !db DATE tddE. ' OB m <br />"` ECRx",a`� P.17 3iplr PMf3l�t� <br />i•'.wL.!� nttr�n af[. "LOCw-- TR[7Kwt +Z7 tf. _EtlltEtA4_D <br />r( <br />V <br />t' 9 <br />n% <br />V , <br />fr <br />i <br />
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