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Q <br />4 a <br />f <br />L4 <br />Dr. L. E. <br />Imes <br />PHS- 70e(VS) REV. 7-66 <br />DEPARTMENT OF PUBLIC HEALTH, <br />STATE OF NEBRASKA <br />EDUCATION AND WELFARE <br />DEPARTMENT OF HEALTH <br />Bureau of Vital Statistic,a <br />BIRTH No. 126........ <br />CERTIFICATE OF DEATH STATE FILE NO <br />- <br />r <br />--I - <br />- - <br />- -- <br />^Q <br />N <br />I` , <br />sWyy <br />Ome y <br />�F <br />B <br />� 8 <br />i� <br />PLACE OF —DEATH p UUSUAL kEaIDLNCL (Wh d - eed IWed. 1[ ImGtuGon: <br />. coI)NT'Y Hall 'FATE Nebr. " �rlilil betoro sdmlalon). <br />b. CITY (If outside corporate limit-, writ R Ij LENGTH pF CITY (If t d por°te I t write RURAL) <br />TOWN $r and I STAY 0 TOWN ci'r &Rd Island <br />d. FULL NAME OF (It no[ In hapitsl or ,neti[u[lon, givae�Qd t d. SORE (I! rural, glue loation) <br />IINSTITUTI NR St. Francis HoeDitJ�'lareee) ADDRESS _ J_16 E. let <br />$ Y. NAME OF a. (Firer) h. (Middle) - -e. Itre[) 1. DATE (Month) (Day) (Yar) <br />DECEASED M.0 Mary Louise Leuthaeuser DEATH Mar 26 1958 <br />J <br />COLOA or RACE T. MARRIED, NEVER MARRIED. 8. DATE OF HIRTH 9. AGE Hn yre. If Undae 1 Yr. It Vndee 21 Hra. <br />F W WI�82 TledoncED (spri ify> 12 -31 -73 .y qo- na.Y) ¢ys. seer. Mm. <br />Oa. USUAL OCCUPATION (Give kind of work 10b. KIND OF BUSINESS 11. BIRTH- (City, townt3or4 uvtY) StGate 12. CITIZEN OF WHAT <br />v d [ g II[e, if xGred) OR INDUSTRY P torsi tr ` CO 7 <br />tiv At Home AVe Wiese ermy$n 1 <br />I It, FATHER'S NAME IIa. MOTHER'S MAIDEN NAME 11b. NAME OF HUSBAND OR WIFE <br />�kl Karl Kooh Albert Leuthaeuser <br />Y 11. WAS DECEAS E fER IN IT S. A: drtee .011.CEVS? 16. SOCIAL SECURITY I1lbe t NLe 11"' ac,ue tr ♦ Add - <br />(Ya, ae. m r Till <br />18. CAUSE OF DEATH MEDICAL CERTII+TCATION fnterral Batwwv <br />$oter only om uvee a[ L DISEASE OR CONDITION Onset <br />DIRECTLY LEADING TO DEATH- Ma <br />•T61a daaa net mesa the ANTECEDENT CAUSES <br />Saab d l-ra, u DUE TO <br />Part { mamwa tM dif Morbid ronditiooa, if an Y, fhinf <br />rhr W the -bore aea (a) satin( <br />aw, Werr. ar ed d-fl- tM and<ririnf caa Iu4 DUE TO (c)...._...._... <br />tNv abk! rsamd death. ^""".""'1"''L'.'..._ .......... ...._................. ......'_. <br />�� Y IL OTHER SIGNIFICANT CONDITIONS h(a, }�yV4 ` <br />O Cendltlopa tribaAnf le tM data bat at Y <br />nlatad to 1►a dlaw or rondlllon uvalaf Malh. <br />19a. 4T E OF OPERA- Igb. MAJOR FINDINGS OF OpERATTON �eyt t, 20. AUTOPSYT <br />TIDN $•s•57. aa....e...�ev.'L.y pGbilM1�/'t a +w� Ra"((w..a <br />3 -LI -i /.uauar YaE3 No <br />21. ACCIDENT (SwIfr) 21b. PLACE OF INJURY le.f., In r about 21e. (CITY OR TOWN) (COUNTY) (STATE) <br />HOMICIDE home, term, factory, atreet, offiea bldf., ate.) (If runt area, write RURAL) <br />Yld. TIME (Month) (Dar) (Year) (Aou:) 21e. INJURY OCCURRED 21f. HOW DID INJURY OCCURT <br />OF Whil at Work El <br />INJURY m. Not While at Work 0 <br />22.1 hereby cortt;g Litt 7 atte>Ided the deeeosed. from ...._:..3..., 19(7.., to......3' 3'.6......, 19:!...., that I teat Sato the de- <br />ceaaed aN _.3.- ..E..O., 19Sj..., and that death oem"ad at jktrkm, from the causes and on the date Stated above. <br />Yta BLGNF.TjD:.T ie (4gree oe Gtp) 2Yb.�t DDRESS � ` 2fe. DsATE BIONED <br />21a. BUMAL ft[ 216. D TE 2'c,. NAME OF CEMETERY OR CREMATORY 21d. LOCATION (Cllr, tow-,'ele uy) (Step) <br />9I CRaM,,'ION ❑M 3- 9 -E _eat Lawn Me m Ial Par Ilrand elan Neb a <br />g A&YO \'AL 18peGfy) 9 142 0.4 <br />DATE .+EC'D BY LOCAL R- 01-P �Cb'A �' _ <br />n <br />tJ�o7 . <br />tJ�o7 . <br />