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x„ <br />1Ytt <br />Division of <br />DEPARTMENT OF COMMERCE <br />Vital Statistics <br />}g) <br />'area - of tae case STANDARD CERTIFICATE <br />OF DEATH stag Fne�7a_9054 <br />( <br />STATE OF <br />NEBRASKA <br />!I !tt <br />1. PLACE OF DEA <br />Couna �_�i <br />2. USUAL RESIDII7 OF DWEASED: <br />(b) City or to� r <br />(a) Sbts C. <br />( <br />outelde c o b IimI4, wrib RU <br />< amo 1 or Iast ) <br />(e) Cia or ! <br />I <br />X111 <br />(If not th star In netiltaloo writ• ste•at -amber locatloe) <br />(d) of clay: Ie haDltal Institution <br />ou eta miss, wtla RURAL) <br />(d) Stnet No. - <br />1 ' <br />or <br />In thin commuWa '.,a�I,,,� (S It7 wh•taer <br />his co {` <br />1'� �,.� RNa IM) <br />it d <br />-�_- y^ <br />moutW or day _ V — <br />(a) U fonieo born. how lone h O. S. A.T <br />) ®IC "��OyBQ��Cjj�����G1lON 1- <br />YD. Date of drib: i1 an <br />hear � mtnab <br />2(a) FULL NA <br />! <br />8(b) If reteran. <br />Qacme <br />war _ — - - -- <br />21. I it r artify that I attended the <br />L Color r�/ BW Sh le. wldowsdt mm///aa/rr <br />zW. diyond�� <br />- -�..i� -_tee• ly ' <br />that I <br />— e(c) As. of husband or <br />and that drth occurred a Lhs dab sea boar stated -bar•.... Daatla <br />2!9 <br />T. Bir data of <br />_ <br />( • I (.y1 (Year) <br />L AGE: Years Month If lw thw cos dy <br />Due b <br />77 I� <br />Due to _�.._�- - .. -__+ <br />•�- . -..� -. <br />r <br />L 'IrthDlaw <br />(Oia. town. or as 18bb oe tote)'' noun ) <br />Other coedltlo as <br />(Include Dngaawi wlthb a maths of daatl) <br />pHrallZA i <br />1a. Usual eecupstla <br />lI. Imaaetry or bve- <br />TfaaaHtw <br />gW* analaax <br />18. Name <br />Of oDarations <br />tM 4=10 Is <br />S BI tbDl <br />- --- -- <br />Wall Math <br />-. -- _ <br />y{ (Ci ojJ or county) (S to or forafra ) <br />^----- �'- �'--- ---.�" should bo <br />saa sM,.:.. <br />Of autopy ry1 <br />(1L Maldm Dame Cf.�_ A <br />- - -_ _ - <br />16. <br />g Birthplace <br />S` <br />>� (cTa— _town. <br />� - - - -_— - -' -M_ tiodaaib: : <br />ae a unTs) gr r i <br />22. If death w due to wow-1 e' m the :enawhiex <br />16 (a) informant slsnabx <br />.y <br />(a) Accident, suicide, or homlelde <br />(b) Data of occarreea —� - - <br />thereof (zz:.. <br />-- - -_ <br />(c) when did Injury oaeurT <br />( rlai, etamatlon:..e remoraI t ) ) <br />(e) Plea: burial wr crematk, _ <br />(d) Did Iwory —Al. or hoew. a farm, b Ie www rises. <br />; _ <br />3a (s) Sienatun o: s-ai d -. � <br />(b) Add;w. ..�iw�. <br />public it aw of <br />":� n —_ <br />WhIL at <br />w <br />Ile <br />32 c.> �� V .i'T lr _✓ -_ <br />i <br />(Date. +< ^hr d Leal reebtrar) � (LKLt. W x afenatnn) <br />2a. slim. -.. <br />D. <br />Addrea <br />1 <br />1 � <br />December 2, 1 <br />,Q1,j <br />