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006-459
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4/12/2012 9:05:09 AM
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006-459
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In th <br />Do is <br />Form <br />143--4 STATE OF NEBRASKA Do not write <br />D—,-..t .1 H—th—D-i .1 viw <br />. . ................... G- 3.1187 <br />To—, . . ........ — CERTIFICATE OF DEATH <br />If <br />drib :u <br />In <br />.... .............. i_ T . t <br />of <br />of <br />L—th of —id.— i—t, to.. M b.,. <br />-- H*- U. a. if of fw.iw, birth, <br />2. FULL NANIZ j7=;LL:L.Z <br />p rARTICULARS blEDICAL CERTIFICATE OF DEATH <br />S. SEX 4, —COLOR OR 6. SINGLE <br />RACE M no.) <br />121. DATE OF DEATH <br />lis. If in <br />.U.= <br />WIFE of <br />S. DATE OF BIRTH <br />dr) <br />7. AS. Yrr. r Yo <br />D. <br />If I— thu, <br />a. T-M <br />kind of it :. , <br />Sl :Fk <br />ih= <br />b. Id..M., hurt—. I. -h" <br />wor <br />brok <br />lint. d--.,l L.t wkd a t 11, <br />(-.-In — <br />T-1 tl <br />.-or - <br />......... . <br />� <br />City or To <br />13. Birtkpla" <br />II 14. lfirthpl� J City or To— — — . •t, -- .d ,—_4 ....... ......... <br />— --- -- ------ _�:- I I <br />16. Birthplace Cltr or T.,-.. .. ......... .. . <br />* K.,b- <br />I ....... ... <br />17. INFORMANT <br />I.. <br />P�l 7 <br />-- --------- - . .... Ylay. 3 w:11) <br />--l". --== lq—a.�dnha I. m <br />Th. MI. .11—d — th. "I. ,N b_, a..._... 44.r� A IL <br />Th. of d_th ..d i..d on.... of hV,. . , erdh, <br />of <br />... ........ ............. .. - .............. ........................ ....... . ... <br />....... ........ ............ .......................... . ........... <br />................... - ............... ........ ................... .............. <br />........... . ............. ........................ ............ . . <br />Contributory ct— of innipor—p. ... nl.t d 0 Illimelpal se, <br />.......... <br />..... .. .. ... <br />..................................... - ............... . . ...... ...... <br />n,Mt <br />U. If d.th — 41. W -1-1 Ub. f.6 <br />la,risir: <br />...ident. ,Iid, or hoori,14,? ................ ]).t. L__ <br />WM. did i.J." —or? ......... ............ . <br />ulty - tu.q —1, rim num) <br />SPQcHy wh*tM' IJ'" ort"M Is ibdu"W, In boa% Of I& P►lb <br />pl... <br />Iff—w of injury .............. .. .......... . . <br />N.t.- of ij.r . ........................ ............. <br />24. Ww diana•e or injury in guy utii, rnhithh, 1. of d. <br />
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