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. <br />■ <br />PAS- 798(VS) REV. 7-68 " STATE OF NEBRASKA <br />DEPART(n'ENT OF PUBLIC HEALTH. DEPARTMENT OF HEALTH <br />EDUCATION AND WELFARE Bureau of Vital Statistics <br />BIRTH No. 126 -------- CERTIFICATE OF DEATH_ STATE FILE No — -,_ <br />_- - -- _ — -2. USUAL RESIDENCE (Wh - deeeesed 1 ed If in Ht ti - �(dence <br />e <br />I. PLACE OP DEATH - - e. STATE b. COUNTY = albetore admission). <br />COUTM <br />Its Rural) L E N G T H OF r. CITY R (If outs d porete limits, write RURAL) <br />1. CITY (If outside ronna limits, ar STAY :_elton rug nl l ) <br />OR GrM.Island TOWN <br />TOWN etree d. STREET (If rural, sire locatlon) <br />d. FULL NAME OF (It of In hoePitsl or metiwtlon, sire ADDRESS - ml • East _ <br />.sore e)', 6 i Id . <br />HOSPITAL OR 3QS'ltal _ -- <br />INSMUTION S t .Fr'_ :Weis br lMlddle). ___�— -c. IL.st)— — -�.. DATE (Month) (Dq) (Year) <br />a. NAME of t—st) DEATH Jan. 16 1:' S8 OF <br />DECEASED ami tl__ _ <br />or Print) Jennie <br />-- Under 26 Hrs. <br />6, SEX 6. COLOR or RACE 7• WIDOWED. DIVORCED R(Sperity). S. DATE OF BIRTH 9.IYCE.II d")I I�MU^ rD1are Hoare I Min. <br />female <br />white married 11 -9 -187 _ gClr(G� w <br />Aooe. USUAL US� OCCUPATION PATIO¢ li sire kin t of dr;4 lOb. KIND OR OF INDUSTRY I1 PW CE (C tr. town <br />r [ore[¢n country COUNTRY? <br />Statd.l2. COUNTRY t WHAT <br />t1OuSe rri eeren rc s1 1 St.PaU1 ire�r U.S. <br />lea. MOTHER'S MAIDEN NAME 14b. NAME OF HUSBAND OR WIFE <br />16. FATHER'S NAME Vale�ne Fd. Smith <br />Joseph Dunn Sarah <br />16. WAS DECEASED EVER IN U. uARMr Via. ORCES Tce)', 16. SOCIAL SECURITY 17. INFORMANT'S NAME or S{¢natute t Add.. <br />(Y «. aq or ya�orem (It 7«. ¢Iw. o err - - Ind ,�, mi th, Shelton Nebr. <br />MEDICAL CERTIFICATION Inar..l S.tw «n <br />is. CAUSE OF DEATH Onset and Deatb <br />Eaar on17 one eau« at I DISEASE OR CONDITION 7 <br />U. for la)• (b). end (I DI •DIRECTLY LEADING TO DEATH- (a). (!(• Y.:. t�l.% �tararr .� .......................... .. ........ a.................... <br />.. <br />........ ........... -- ..... ........ ........... ....... ...................................... <br />... <br />-- 20. AUTOPSY' <br />Ae <br />OWNa RURAL) <br />(STATE) <br />I <br />(INJURY OCCUR? <br />4.1._ 16. ..., 19th..., that I last saw the de. <br />the causes and on the date stated above. <br />26e. DATE 826N8D <br />�24d. LOCATION l It7, wan. or eo¢nt7) (Sao) <br />randIslard Nebr. <br />TOR'S 91GNATU E DRESS <br />7 t ✓...% <br />�G 3 <br />