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1 <br />1 <br />I <br />ml <br />1'i. I <br />sI REV. a -sr STATE OF NEBRASKA <br />DEPARTMENT OF PUBLIC HEALTH, <br />EDUCATION AND WELFARE DEPARTMENT OF HEALTH <br />' Bureau of Vital Statistics <br />BIRTH No. 126........ CERTIFICATE OF DEATH STATE FILE ND.. _.. _. <br />M <br />r� <br />N' <br />z <br />a <br />pxp <br />C <br />a'\ <br />€e€ <br />S <br />V <br />1. PLACE O[O[ATN <br />a. COUNTY <br />2 USUAL RESIDENCE IRA. 1.1 II— IIHT .1n R—dw eanV-) <br />Hall <br />A <br />n STAi CO UNH <br />Nebraska Hall <br />A. CITY. TOWN, OR LOCATION r. LENGTH OF STAY IN IA <br />r. CITY. TOWN, OR LCCITION <br />Grand Island 21 years <br />Grain Island <br />d. NAME Of (( /no( in honpi[a/, Vic[ afrr<f addr[ea) <br />'UAL ON <br />d. STREET ADDRESS <br />N DTIONVeterans AEh RIstration Hospital <br />r. IS PLACE OF DEATH INSIDE CITY LIMITSI <br />1� _ <br />u Z--Z <br />e. IS RESIDENCE CITY LHI�l <br />f IS RESIDENCE ON A FARM <br />YE NO❑ <br />YES CO No <br />YES NO Ct <br />3. NAM[ Os Fire( Afidd(r Lae! - - -- — <br />D[C[Af[O <br />d. DATE Mon(h Dny Year <br />IT".,P,W) EARNEST S. ERICKSON <br />OF <br />UCATNApril 3, 1958 <br />5. $f% <br />6 COLON OR RACE <br />] MAPRIEO $] NEVER MARRIED[.] <br />8. DATE OF BIRTH <br />9. AGE (/n y[are <br />UxpER I vGR li UNDER S. HRS <br />Male <br />White <br />DRIVE, oncED <br />10 -6 -91 <br />66 yrs. <br />5 °°7 x. W... <br />11)1. USUAL� OCCUPATION fCio<kindo /work door <br />IDDWKINOOF[USINESSOR INpU5TRY <br />11. BIRTHPLACE (�Va([o. fo[eipn roun(rY) <br />12. CITISFN Oi WIUT CWNTRV[ <br />Cu9LOC1Y11 arA1nph�O<n grehr[e) <br />vernment Hoepit <br />Oak, Nebraska <br />U.S.A. <br />I31. FATHER '5 NAME <br />1I.. MOTHER'S MAIDEN NAME IA. <br />NAME OF NOSBAND OR WIFE <br />Carl Erickson (deceased) <br />Marie Slatt (deceased) <br />Ebba (Roos) Erickson <br />15. WAS DECEASED EVER IN U. 5, ARMED BIRCES. <br />I6. SOCIAL SECURITY NO. <br />I]. IN,ORMANT Addrers <br />--I ]M -i7 to 6 -12- <br />"Yea fo- <br />9 Unknosm <br />VA Hospital Records <br />IB. CAUE[ 01 MATH [E— only one wWe per,ie, /nr (a), (h), and ([).( <br />INTERVAL BETWEEN <br />PART I. DEATH WAS CAUSED BY' <br />CAUSE (a) Bronchopneumonia , <br />ONSET AND [MAIN <br />one month <br />- <br />!IMMEDIATE <br />�C� i�n +, it avY. DUE To (e) ZYmOhOaarC <br />�' °peN:'fi° <br />n. <br />ala(fnp fh[ unGr- OE TO (0 <br />D <br />rump a roe(. - - -— — — <br />o PART II DINER S- 111CANT CONDITIONS CONTRI.DTING TD DEATH BUT NOT REUTEO TO THE TERMINAL DISEASE ConDITION GIVEN IN P ART I(nl <br />A <br />��{ ORMEDTY <br />< <br />L hosarcoma involvi thoracic and abdominal 1 h node to ch <br />ViS NO ❑ <br />1= 20a. n 8n IDOT41epI <br />sIe)D86RIBE HOW INJURY OCCURRED. (Enf[r Halo[[ o /injury In Pdr(I or Part ,! of if[m ly.) <br />W ❑ ❑ ❑ <br />OF <br />i 20[. TIME oP Hoar Mon(h, Day, Y1ar <br />INJURY <br />I 2Jd. INJURY OCCURRED <br />201. PLACE OF INJURY ([. 0. in Or aAOU/ Aome, <br />20f. CITY, TOWN, OR LOCATION COUNTY STATE <br />wN ILE AT ❑ HOT WHILE ❑ <br />WORK AT WORN <br />farm, fMOry. dr[[l, Odi[! Udp., «[.I <br />21. .ttended the d..... ad/rom 2 -17 -58 ,1. h -3 -58 .nd(..tA.w ,;Yeon <br />Dp-h oceUrretl.t n the d.te.t.ted.bove; and to the beat o/ m, know(sdie, from the —ae, Stated. <br />m <br />J1 JLI (D[p[N or 11[11) 27h ADDRESS Plt, DATE SIGNED <br />SPA <br />T. S 0S3 M.D. Pathologist VA Hospital, Grand Island N b 4-4-58 <br />23BCPEMATIEN, 23D OAT � E�OF CE TERY P TORY 23d. LOCATN)N (Ci(y, loNn. or [oLLnly) (S.l<) <br />B*ft1hT& t aoval 4/7/5 i em&"E�e`tiy ^ ^ Ed a <br />