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T ,,Grand island. ?oyrs <br />1 ST R F'F'.l' .If :urxl. �i.e la'x:1 nl <br />d_ tl'LI. N.1 \IF. OF �l[ not in hn�t�i!nl or in..�.u.�ui.. �nld -c� =t '.ICIk;ESS <br />NSTT..1.OR 1420 North Sycamore St. <br />L. ISSTITCTIUN Lutheran HOSpital <br />3. NAME OF n. 1F'ir_tl b. iMildl�1 r. iLxtl J. DATE i)tonthl lDe >') ll'rarl <br />I�E1'F.ASF.0 Leverna �"ereie Iverson 11 F1ATly/l�y 28.1955 <br />1T--- u; Pri" <br />S£X 6. t ,l -OIt ur t:.l.E MARRIED. N'E\'F.R MARRIE1', 1. I'ITE OF BIRTH :'.: \t:E (In ayI If Under 1 ). It Under .d Hr•. <br />In;.tryhdaYl ,ty. Diy'�y Hours M- <br />SEX 1,1\'OItt ED iSt +e'.IV) 1 1 11 <br />Female White Married June 17/1904 <br />In. I'SU \L OCCUPAPoN Gi:. kild �f —k 1,b. KIND OF' BUSINESS ll. BIRTH C'tY. tn..n ntYl IS e I_. CITIZEN OF \Y} {; \T <br />OR 1.N l; STRY I`L:\ rory t8n tr 1 ,TRY ". <br />to "f"' k' we.e..n if -6 -.d1 Housewi >ea dherokee, focvd <br />'home {t - <br />t Is. FATHER'S NAME ` IJU. MOTHER'S MAIDEN NAME lib. NAME (1F HUSBAND OR WIFE <br />J. E. Dolph Tillie Farquar Elmer Christian Ivenaon <br />1'.. WAS DECEASED EL'ER IN U. S. ARMED FORCES' „�. 1. \L SECURING 17. INFORMANT'S NAME or Sig,nov, A Add...s <br />a (Y,., ne. er unknown IH Yes. .r or d. s of <er.,r,507 —N4 -1744. �6114aukes <br />No. Robert E Iverson. ft so. <br />�'- -- - MEDICAL CERTIFICATION lnter.al 111—n <br />18. CAUSE OF HEATH Onett and Oeeth <br />1 � En[er only one rau =e M: L D,SIFAIF. OR C )NDITION / <br />tiS line for (a) (b), and Ic) D1 REt TI, Y LEADINC TO DEATH' -, <br />.) 10, <br />eThl. doer net mesh the ANTECEDENT ( AU SES DUE TO (b) <br />_.... <br />mode of dying. .,then:,. Morbid enatitihne. If any. ¢Tin¢ <br />heart :,tier,, ....e (e) et.tin¢ <br />etc. It mee.1 eom Phce~ the to the ing clue tut. DUE - - -- - -- -- -- - - - - -- <br />.. eue, Inlorl. underlying TO Ir). ' '- <br />tlox which c.uecd death.. <br />II. OTH F:R CIt:Nr}'ICA NT t 11N DIT:ONS <br />- ('hnditions con tributin¢ t` the death but at <br />b' related m the dl�,e.ve or anditlon c ... id. death. 1. AUTOPSY" <br />t9s. DATE OF OPERA 199.. MAJOR FINDINGS OF OPERATION Yee 0 No u <br />E 21 h. FI.ACE OF INJURY (e. c., in r about _Ira iC TYr OR TOWN) le RURAL COUNTY) (STATE) <br />'!la. ACCIDENT (Sl"cilY) home, farm. fnctorY. street, offi- bid¢., ate.) ru x ¢me, n - <br />6 <br />SUICIDE w <br />HOh1ICI1tF. 21e. INJURY OCCURRED _I[. HOW DID INJURY OCCUR'. <br />r <br />21d. TIME (Month) (Day) [Year) (Hour) µ:hit, nt Work <br />OF m. Not Whih at Work F <br />g _ INJURY -_ <br />PS _ 19f. to .Z_. land ,o these <br />last saw the de- <br />2. ]hereby certify that f attended the deceased death o <br />19.. ...¢ /, and that death occurred at`�P �rn., from the cmascs and on the date atatcd above. <br />ceased alive On ..�_i.� - jy _ - - or title) :eb. DDRF.SS TE IGNAD <br />I la I— 11 PA S <br />28a. SIGN UR� <br />p 21a AG -1, :tb., PAT& tIe. NAME OF CEMETERY Oft t'REbfATORY add2dd, L0 (City. town, <br />lowa. county) l tat,l <br />OREYATIOh Q #u gust 2. 155. Graceland Park. 'Sioux City. <br />REMOVAL , jl3nect - <br />RE R <br />'�[¢ <br />._ 5 SIGN R k "N AL <EITUR'S SI' ATU �'T> <br />UATE REC <br />Issued October 29, 1959 <br />• <br />3,r f <br />is <br />