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;EDUCATION , AND VVBL.L
<br />B RT
<br />I PCACIE: 00:0EX
<br />T"
<br />b. CITY. TOWN OR LOCATION
<br />1,c. 'LENGTH OF STAY -IN, Ib
<br />12
<br />_.TV rniiiii nR LOCATION
<br />C.. CITY.,._T,0W`W OR,LOCA
<br />I el � d''Zslahid
<br />Gr4M
<br />1, ebr
<br />- I d. NAME OF (jfnoj in hospital, give sired, address)"
<br />CD
<br />HOSPITAL OR
<br />INSTITUTION -7th
<br />INSTITUTION� 1323 W.
<br />3 2,3: W,.- 7th
<br />e. IS RESIDEN I CE INSIDE CITY LIMITS?
<br />J. IS RESIDENCE ON A FARM?
<br />Z.0
<br />YES NO
<br />YES MOO - -
<br />YES 0 NO 19
<br />3. AMIE OF 'Mrst Middle
<br />DECEASED j,
<br />(Type or print) He my
<br />Last
<br />T j ads n,;
<br />-01.
<br />Month Day Year
<br />Feb 14,1959
<br />5. SEX 6, COLOR OR RACE
<br />7. MARRIED:0 NEVER MARRIED
<br />DATE OF BIRTH V. A1.t tln years
<br />l2f§irthd.N'
<br />lyr
<br />IF UNDER I YEAR
<br />H
<br />_"
<br />I H
<br />M W
<br />18,
<br />I
<br />PIy '0
<br />LJ
<br />E S!
<br />I I '
<br />10a. US N (dive kindqftq?,kjoje
<br />USUAL OCCUPATIO
<br />;EDUCATION , AND VVBL.L
<br />B RT
<br />I PCACIE: 00:0EX
<br />T"
<br />b. CITY. TOWN OR LOCATION
<br />1,c. 'LENGTH OF STAY -IN, Ib
<br />12
<br />_.TV rniiiii nR LOCATION
<br />C.. CITY.,._T,0W`W OR,LOCA
<br />I el � d''Zslahid
<br />Gr4M
<br />1, ebr
<br />- I d. NAME OF (jfnoj in hospital, give sired, address)"
<br />d. STREET ADDRESS I S
<br />HOSPITAL OR
<br />INSTITUTION -7th
<br />INSTITUTION� 1323 W.
<br />3 2,3: W,.- 7th
<br />e. IS RESIDEN I CE INSIDE CITY LIMITS?
<br />J. IS RESIDENCE ON A FARM?
<br />IS P ACE OF DEATH INSIDE CITY LIMITS?
<br />L
<br />YES NO
<br />YES MOO - -
<br />YES 0 NO 19
<br />3. AMIE OF 'Mrst Middle
<br />DECEASED j,
<br />(Type or print) He my
<br />Last
<br />T j ads n,;
<br />4. DATE
<br />OF
<br />DEATH
<br />Month Day Year
<br />Feb 14,1959
<br />5. SEX 6, COLOR OR RACE
<br />7. MARRIED:0 NEVER MARRIED
<br />DATE OF BIRTH V. A1.t tln years
<br />l2f§irthd.N'
<br />lyr
<br />IF UNDER I YEAR
<br />IF UNDER 24 HRS.
<br />_"
<br />I H
<br />M W
<br />18,
<br />I
<br />crept 18 9 1909 .
<br />S
<br />LJ
<br />- I 't
<br />I I '
<br />10a. US N (dive kindqftq?,kjoje
<br />USUAL OCCUPATIO
<br />WIDOWED C1 DIVORCED
<br />10b. KIND OF BUSINESS OR INDUSTRY
<br />R�
<br />1. BIRTHPLACE (State or joreign country)
<br />1Z. CITIZEN OF WHAT COUNTRY?
<br />king I& es . . d)
<br />A cle jn4f retire
<br />fj�gTfgwor a Amar
<br />Am. R pill- 1-1-0-1
<br />Sao 14acon, Nebr,
<br />USA I
<br />far , factory, street, office bldg., etc.)
<br />14. NAME OF HUSBAND
<br />OR WIFE
<br />>4 . 13a. FATHER'S NAME ISI). MOTHERS MAIDEN NAME
<br />M q nn" m mijaden Hemke Saathoff?
<br />Ida Tjaden
<br />-.-
<br />�Q 0.z Z
<br />W
<br />Zb .5 -0
<br />°roxro
<br />.4) H
<br />10 x 0
<br />u 0 ,, >,
<br />5,00
<br />> U.0
<br />0
<br />CA E
<br />a'vo a1
<br />00
<br />OW 0 a
<br />0
<br />o.
<br />Osu
<br />0
<br />-0
<br />t
<br />M)
<br />H N 4
<br />Z L-4 N
<br />15. WAS DECEASED EVER IN U. S. ARMED FORCES? 16. SOCIAL SECURITY NO. 17.
<br />(Y ..ii6.k.) if, ga, data of 8-ii") 508-30-908
<br />INFORMANT Addreaa
<br />Mrs. Ida Tjaden, Grand Island, Neb
<br />I
<br />INTERVAL BETWEEN
<br />18. CAUSE OF DEATH [Enter only one cause per line 7(a) it -(b). . (0-1 ONSET AND DEATH
<br />PART I. DEATH WAS CAUSED BY: Acute Anoxemia
<br />IMMEDIATE CAUSE (a)
<br />Carbon Monoxide poisoning
<br />Conditions, ifa% I DUE TO (b)
<br />which got, 'is' t
<br />above cause (a),
<br />z
<br />0
<br />stating the under- DUE TO (C)
<br />lying can . e last.. WAS AUTOPSY
<br />PART 11. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE CONDITION GIVEN IN PART 1(a) PERFORMED?
<br />YES ❑ No ❑
<br />-
<br />20a. ACCIDENT SUICIDE HOMICIDE 20b. DESCRIBE HOW INJ URY OCCURRED. (Enter nature ofinjury in Part I or Part 11 of item 18.)
<br />El
<br />_J
<br />-20C TIME OF Hour Month, Day, Year
<br />LJ
<br />INJURY a. in.
<br />p. in.
<br />o
<br />20d. INJURY OCCURRED
<br />20e. PLACE OF INJURY (t. g., in or about home
<br />20f. CITY. TOWN, OR LOCATION COUNTY STATE
<br />WHILE AT ❑ NOT WHILE
<br />WORK AT WORK Ej
<br />far , factory, street, office bldg., etc.)
<br />1 attended the deceased from to m alive on
<br />21 and last saw hi
<br />the best of my knowledge, from the causes stated.
<br />Death occurred at m on the date stated above; and to
<br />-7 DATE SIGNED
<br />r22a. SIGNATURE (Degree or title) 22b. ADDRESS
<br />Gerald B. Buechler,Co- A tly Grand Island, Nebr
<br />23a. BURIAL. CREMATION, 123b.
<br />DATE
<br />n. NAME OF CEMETERY OR CREMATORY ----
<br />Church
<br />T-23d. LOCATION (City, town. or county) (State)
<br />Nebr.
<br />bM1t%11F8h,
<br />Oval 2-18-59
<br />Zion Lutheran
<br />rlemetery-Macon,
<br />1 24. DATE RECD. BY REGISTRAR 125. REGISTRAR'S SIGNATURE
<br />(1,�,'j'dP_'Nneraj Home Grana isianu
<br />1« 5
<br />St,-.te of-Nebraska
<br />C.iurty of Hall
<br />Entered on Numerical Index and filed
<br />for record ii-. Office of Register of
<br />Dt IS on tiie ----- -4-th---- dag of
<br />_ u _ _n.e --------- 19-59- at ----------
<br />o7docl- and --- _3Q. -- rninultes - P- -_ M.
<br />and recorded in Book ---- E - - - - -- of
<br />t page
<br />Register of Deeds
<br />By-------------------
<br />IM ^ � Deputy
<br />
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