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Esureau of vital stg(istics <br />BIUTH NO 126 CERTIFICATE OF`bEATH srATE FILE NO... - - -- -- <br />............... <br />I FI <br />COUNTY DEATH <br />n. CO�.NTV <br />2 USUAL RESIDENCE WA... esw.d l•M Ru•dewrr Delrr adwurvn) <br />Hall_ <br />0 STATE 6. COUNTY,ow. <br />Nebraska Hall <br />h CTV TOWN. OR LOCATiOh <br />r. LENGTH OF STAY IN Ih <br />[. CITY, TOWN, OR LOCATION <br />rand Island <br />d <br />slang <br />!I no Iri A,rlI1(vl. Vur a rrrl vddrre.•. <br />HOSPITAL o <br />d. STREET A:O E <br />� � - <br />NSTiT ii "." St. Francis Hospital <br />7:2 +orth r„ eeler Street <br />PLACE O DF N51,1 CITY LIMITS, <br />r. IS RESIDENCE .N DE CITY LIMITS+ f 15 RE5IDENCE ONAFARM' <br />YESXj NO _ Y X] NO 11 YES❑ NOM <br />NAME OF e.el ,Vidd/r Lae( 4 mP.,h D.y F- <br />DECEASED <br />TV p, a. Pro,rl Theodore Schroeder August 28^ 1958 <br />p[y,� <br />5 SF% 6 COLOR OR RACE i MARRIED 1�I NEV[RMARRIED❑ 8 DATE OF BIRTH 9 rara uNDE vE FUN Ris <br />R IDRHR I <br />E <br />ayl Mvn1Ar MPU1r Mir. <br />N,ale 4lhite w1DOwED ❑ 2 -18 -1905 <br />IN �'u OCCU? /TIONk; Orrl Gind nJ'�Ik(dn�[ <br />IDA KIXDOE BUSiNE550R ..ESTRY <br />I! BIRTHPLACE (.h'IN, o[jP11g 1Pn V) 12. CITIZEN OF WHAT COUNTRY? <br />Darman <br />Railroad <br />Hall County, Nebr. U. S, A. <br />134. FATHER S NAME <br />13b. MOTHERS MAIDEN NAME <br />14. NAME OF HUSBAND OR WIFE <br />George Schroeder <br />Katherine Feller <br />Etteline Ehlers Schroeder <br />15 WAS DECEASED EVER IN U S. ARMED FORCES, 16 SOCIAL SECURITY NO. IT INFORMANT Addetae <br />+.,• Yr. v�•. ua, mdnl.a .,I wnv <br />No Mrs. Etteline Schroeder, Grand Island. Web, <br />IB CAUSE OF DEATH Ih H11 only am taus[ ) r lira fn1 (a), Ibl, and (0.) INTERVAL BETWEEN <br />PART. DEA TH WAS CA USED BY ONSET AND DEATH <br />� ,per "" <br />IMMEDIATE CAUSE (a1 — __. (/My.iw —w �/'Qµ('fLf�.Q (fJ(r�j% lug <br />('ondiliona. rl vnV. DUE TO (b) (ABC /moo <br />- <br />u'AirA ovrr .Ier (v - - - -- -- <br />vbolr :vast (al. <br />alyillp !Ar undn DUE TO (rl_ <br />z lVlaq rnuar (va(. <br />O PART II OTHER SIGNIFICANT CONDITIONS CONERIRITIXG TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE CONDIUUN GIVEN IN PART 19. <br />WAS AUTOPSY <br />PERFORMEDD?/ <br />YES El NO rJ <br />= 20, ACCIDENT SUICIDE HOMICIDE <br />2ph DESCRIBE HOW INJURY OCCURRED (Alfa RVlurr If IIJUIV in Parl for P.,f if ofil[m ld.) <br />❑ ❑ ❑ <br />U <br />20[ IME OF 1A­ .NontA, 11.1, 1'ea <br />- -���— - - - - -- <br />U rvJURY <br />— P. m. <br />I 20d INJURY OCCURRED <br />20[ PLACE OF INJURY ([. q., in or shout Aom[. <br />20f CITY, TOWN. OR LOCATION COUNTY STATE <br />WHILE AT 11 NOT WHILE ❑ <br />WORK IJ T W O ORK <br />farm,!nr(arv. idr t,oJ][[ bldg., etc,) <br />p �y <br />21 l attended the deceased from _1�- (s - I?,I'� to .._Q' 24' �d end leaf sew alive on �17 �.� <br />hi- <br />O <br />Death occurred At :1JS A' PA'_ m n the date et,ted.b.v end tO the beat of my knowledge, from the ceu4.e Eteted. <br />22a fIDNATU ( [Orr[ 0r NI![) <br />ADDRESS <br />22c. DATE SIGNED <br />9. e <br />.e J [�4�J hL� <br />1- If-✓a' <br />23a BURIAL, CREMATION <br />23D DATE 21, <br />NAME OF CEMETERY OR CREMATORY <br />23d. LOCATION(( ""' Ill'n. 01 county) (Svwt) <br />REMD�ui� ' <br />8 -30 -58 <br />,tiestlawn Memorial 'ark <br />Grand Island, Nebr. <br />24. DATE RECD. BY REGISTRAR j25. REGIS S 5 <br />126. EUNERAL DIRECTOR _ <br />I <br />