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l <br />k� <br />f <br />H <br />aureau of Vital Statistics <br />BIRTH NO 126____._ CERTIFICATE nP nPemu <br />1 I PLACE <br />CO1 OF DEATH <br />CO�NTV Adams <br />2. YtSTLER[[ID[NCEIWA..edm . rd HwE. /IVIU.I,ew'Roidr.0 YVwe.Mu.ie.) <br />Nebr <br />_ _ <br />6 CITY TOWN OR LOCATION r. LENGTH OF STAY IN Id <br />r. CITY, TOWN, OR LOCATION <br />Hae ~Inge_ 1# yrs <br />Doniphan <br />d. NAME OF II not On <br />HOSPITAL OR PII pIr[ nlrre! oQQrr.rel <br />U_ STREET ADDRESS <br />I ,TION 411 East 5th <br />I . IS PLACE OF DCATH INSIDE CITY LIMITS. <br />J. 15 RESIDENCE ON AT FARM, <br />[. IS RESIDENCE INSIDE CITY LIMITS' +t�� <br />rr��B <br />YES TAI NO ❑ _ _— _ YES I NO ❑ YES ❑ Non <br />3 NAME h'irlf .1fidd(r L.0 <br />*E 4. DATE Month Der y— <br />YN `° Inn Ida R DF <br />Crawford DEATH 8 -11 -59 <br />5 SEA 6 COLOR OR RACE T MARRIED F] EVER MARRIED ❑ R DATE OF BIRTH 9 AGE (1, V[ FUHDERI YEAR UNDER EI IRIS. <br />F <br />17 �1 12 -2 -1869 -S91Ader) VP D,1, R N. Mi.. <br />WIDOWED,y.I DIVORCED O �✓ <br />IDR USUAL OCCUPATION ICU,, kind nfe'o,k done IM KIND OF BUSINESS OR INDUSTRY 11. BIRTHPLACE (.Slnre of Jo gR,PUnl,r) 12. CIOEFN K W1MT fYRRO11Yt <br />d,,,b, HRA1(y(JAT ylfp rrrn 11 ien.rdl <br />At Home <br />i1V U27C 1IC ,, Saybrook, Ill USA <br />13e. FATHER 5 NAME 13b. MOTHER "S MAIDEN NAME 14. NAME OF HUSBAND OR WIFE <br />Simon Cavenaueh <br />Julia Stansbury Harvey S. Crawford <br />I$ Y.r. WAS DECEASED EVER IN U S. ARMED FORCES, 16 SOCIAL SECURITY NO 11 INFORMANT Ad[Tr1e <br />I <br />irerne ^rawford, <br />Doniphan <br />IB CAUU OF MATH )i:'we, only one rawe y[r fine /nF (e). (b), d (r).j <br />INTERVAL • EN <br />PART I DEATH WAS CAUSED BY <br />IMMEDIATE CAUSE ��� <br />ONSET AMO TX <br />— <br />C -din-` If -YO DUE TO (b) <br />an . e'iDi, <br />eu <br />(aline rA, der - <br />2 <br />lyw r (aef. I)" TO ([I____ <br />O <br />PART II OTHER SIGNIFKANT CONDITIONS CONT URUTING TO DEATH BUT NOT R—TEO TO THE TERMINAL DISEASE CONDITION GIVEM IN PMIT I(M1) <br />19. WAS AUTOPSY <br />PERFORMEDI <br />U <br />I= <br />YES ❑ NO IY� <br />204 ACCIDENT SUICIDE HOMICIDE <br />2Ob DESCRIBE HOW INJURY OCCURRED. (E''nle, n—e of$nj -, in Pnrl l o[ Pa[l ]/of Drm 18 .) <br />U <br />U <br />❑ ❑ ❑ <br />2Or TIME OF 1lDU, Mon IA, D.1, Yeer <br />_ - -- <br />U <br />INJURY <br />i <br />20d INIURY OCCURRED <br />20r. PLACE OF INJURY (t. p . 1n or aMMt honM, <br />2D/ CITY. TOWN. OR LOCATION COUNTY STATE <br />WHILE AT ❑ HOT WHILE ❑ <br />I °•m, I°rro.r. enrrl, offin GlEd_ rt[.) <br />WORK AT WORK. <br />_ <br />21 1.1—dsd rh d Rsiffi peg -`;,�� %�_ <br />toS- <br />Deeth oc [ dyf •..;:, / - n the d—•toted above end to the best of my knoWled�e, from the a ne eteted. <br />22 RIO . Pr ID(r <br />7L[. OATE SIGNED <br />YZ <br />230 QLMR pA}'F -- NAME OF CE ETERY OR CREMATORY <br />oar �SewCemetery <br />2,. IOCA IOM ( yf,, loton. 01 [0 Ir) (STele) <br />D()nip�lan, 11eee r. <br />-- <br />n , <br />C23 5- <br />
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