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I <br />I <br />.l <br />r <br />STATE OF NEBRASKA <br />DEPARTMENT OF HEALTH <br />DiAston of Vital Statistics <br />li STAN16ARD CERTIFICATE OF DEATH <br />1DEPARTMENT OF COR <br />i BUREAU OF THE CENSMMEUS CE <br />i <br />Soda] Saeurity No ........... _ ........... ....._.........._............_. State File No.._._.................. _.................... <br />1. PLACE OF D-11: 2. USUAL RESIDENCE OF DECEASED: <br />r (a) Covuty ............. h811..— ............. <br />............... ---- ........ ................._............_ (.) state.. (b) cemw ....Hall.__.._._............ <br />11) City or town.GXA_Ud....15. a?1d.r....111ebx.........__ -.. rand I s1Ana......._...._. <br />(If outeide elty or tow. Bmtte, write RURAL) (e) City or towv.... .�'..'......._._....._......_._ _ — <br />(e) Name of hospital or ILdtvu... (If outeide city or town BmRS. brim RURAL) <br />LutheI'An riospitsl <br />._.. ........__....... <br />_..._.... (a) so-ret x .. ...._u.e.....,.ts_t.ti._.iereat d... eeade....__.__. <br />(I[ not in hoeaital or ioeetutiov. write street uvmber or loeaeou) �� (If r.ral ¢iw locatlon) <br />(d) Length of at": In heoDital or, Ivetitation..._., b..._ �� ..�}! ......................... 6 'Y `0, <br />Iv th4 (e) If forel¢n born. how ion¢ In U. S. A. 1......... ...__.xx. ............ <br />....y.are. <br />community...... G.. 17.@.._..-......,,`[[. E. 9 .L.S...__ ...................._. <br />(Specitl whet &r yre.. ma., or days) ...... ���- MHDlpAL F.RTIF[C TION - <br />20. Data of d ..41"".day___.. -- -- ..._.....19.1 <br />.,tells late <br />f¢a R �y <br />4 - ................f- I . .. �}. .. ..__...._...._M. <br />S(a) FULL NAME ............._...._.................._......... N .il�'_i?_E.X.:.............._._ . I hereby ti[y that at dad t f - ' <br />g(b) If veteran. 19 to... ..... S ...............1L- ..♦ <br />Hama war:........ ........ ... ...:... ... .__... ..... ... <br />..._......_._ _. <br />6. Coloe or e(.) <br />St. 1. wid owed. married, that I leaf caw h....sitve oe... .... -_ -... __._.._,..... 19.. <br />and that death occurred o. the da and hour elated above. Dor on <br />divorced_jLaX_r..",d I i cause of dal ...._.... ...__... .._. ....._ ...... <br />._.. .._ <br />e(b) Name of hmEend or w1fa ¢(e) Asa of hvband <br />...._.............. .......... _..._.—.._...._ ..... .... _ ......................... ...__._......._.....:. <br />7. Birth data of den - ved.......JIM.a_............_. ...._.__....1.8.7.3_... Doe to...._....__ L'._._.._.._._.—.__ . ................................... .._.__._ ..... _........ <br />(Month) (Dp) (Year) t <br />a AGE: Years I Montle, Days If I- than ova dq ....-'.._..._.__..._.....___._...__......... _......._._ ..............._.... ....___._..__._... <br />Daa tp..._._.�_ ..... __ ....... _ ...... <br />_ <br />67 11 16 _..— _........hr. __min. _.�— _. —._ —.. —....__.__............. _ ----- __._....._._..... <br />Other .... —. <br />9. Eltthla.ve. ..... Calu1,v � -.Q:d' $__._.— ...._..__..—_.._ (n ode Dn¢nant9 within ! nweths of death) PRYSICIAN <br />I v <br />(CW, town, or comb) (Stets or torei¢n oTmtry) <br />. Usual oe— tIon......_t10 U,y @_;i.],- •f,.$_. . -..... Major fmdin¢e: =rRw <br />i . Industry or budneu. ....._..L.XX._.._..._.._._..._. Of operation. ... ..........._._.__......._._.._. the eases to <br />wbo 4 b. <br />12. N.m. ... _da- mea.M i.11. era ................._ ..._....._.............__...... ...._..._......_._......_..........__. .._..._......_................. _.........................hoots h. <br />Is. BothD4ea...... _W_&....._..._.........__ ....:. .. ........_......_:._._ v . ....................................................... cl� at•' <br />.....(State,or or .. Of �utowy........._._......_._ ................... ............................... <br />�. (IXw. town, or ooeew) (State, or foreign cou.try) _ ' <br />ie_ M.Idan e—X XXX....__.....__..__..__......_..._. .......__..._.._._ ............. ........._...... ,................._ <br />16. SlethDlata..._.% i. 7i7LX_......_._.._..._...._......_._.. ....._._ ....................... . It death were dwe - terval ea , till 1 <br />22 to are foilowin¢• <br />! t1 (city. town. or v 1) tore coUVtrY: (a) Accident. suteido, or hoteleWe (aDedb) —..... ......i......_..._...._. <br />16. (a) Informant's own ai¢nl .... �. �d:Q. (b) Date of oceuttence..___._..._ _✓ _ ...... _ .................... _ .... <br />......... <br />(b) wears. d_ 1-9.1 and ,_�l.e.bar�ac- ka..._....._.._ (e) wh.re did won oeenlT <br />j17. (a)..bur.ie........_.._.._..... M Data tbetaoe.117.1.1 45..._.... (clw or eownl (c000w> (B�a) <br />(Bmlal, cremation, or removal) - (Month) (Day) (Year) (d). Did in)u" oecor In or abort home, ao farm, in i.daetsial Plane, 1. <br />(e) Pl.a.; bores o< .Grand 7- and D na _.......__.......... —._.. <br />7� _. <br />l9. (q si¢nata a o< : G eN @� kadeag plakaac_.. of Dlaoe) <br />(b) Addiaea._ Gri).il Cl S F. I73 <U -! 6b 8 <br />��u ..... ...... �..j- 'j._._ <br />19. a)--��ua -�c�_ � _....... tb1..._ <br />0 <br />