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Tex :_ — itirris <br />iiol15t71 -. .,u _-c; , rlo.l.'t:7 >. <br />5213 ° Chen -ril.t Itreot 5213 Clionr�.2lt :street <br />e ... ..aiH C:iY L.M,lSr .. ..- ... .. C T L \. TS ON FAR.' ...._fir. <br />Y+t TJ NO❑ <br />3 NAME OF N`2J <br />. <br />DECEASED . � e _.n , ^F AEA *:, _. <br />'.,,, -., 1.1 ard a rTao <br />u k. nrce !)-Z <br />5 571 - A COL OR OR RACE - - -- H ,A!E K':.: a AC r 30,D.1959 F <br />O L Me., ;edZ N._ (� 'DrR 2..HR5 <br />Ma le 1`E ', hdev A D . ..v M�iwtes <br />< Wdwed❑ D.mred❑ Jun 1, 1899 60 <br />BUSINESS OR INDUSTRY BIRTHP..ACE IS, goury) -COUNTRY USUAL O l ATp. --'16b KIND OF WHAT <br />? <br />12 CITIZEN OF Security Grinrd at '3 �k o:' 1`'.r , r.st Pair_field, 'lebraska U. S. A. <br />- — — <br />I 13. FAiryER S NAME _- - -'— - - - <br />Z; <br />IR MOTHER —GL rJ NAME - -- - "---- -"'-- - -- <br />I <br />z lY n a 1pr m u�eLnr o. +) B abc o cg k dat ( e , " inn Corbin <br />E I WAS DECEAED ER IN S . AM -—CU . ;NFORMNT 116. SOCIAL S O. 'j� <br />NO 507 -24 -2660 <br />-- <br />Mrs C. M. Newnan Nw3 ,hter) <br />E IB. CAUSE OF DEATH (For, only one cease per I'ne (a (a). (b). end (c).) <br />PART I. DEATH WAS CAUSED BY: I `uvweur <br />K ouvv ay1 ear.: <br />IMMEDIATE CAUSE (e I Acute myocardial infarction <br />Cand�nom. Neny. -- <br />ge.,na1p Arteriosclerotic heart disease 2 hours <br />abo.o cease (I. DUE TO (b) <br />s,nt'nq fhe under -- <br />lymq ce�so ba. <br />_ j <br />PART IF TH <br />. OER SIGNIFICANT CONDI71ONS CONTRIBUTING 70 DEATH BUT NOT RELATED TO THETERMINAL DISEASE CONDRION GIVEN IN PART 1(e) I 19. WAS AUTOPSY PER - <br />F4 FORMED? <br />Y —__ __ _______ YES❑ NO� <br />s`20e. ACCIDENT — _____..____.__.. __.__.______.— .. _..__— _ —__._. <br />SUICIDE HOMICIDE �20b. DESCRIBE HOW INJURY-- -- - " - - -- - - - - - -- <br />OCCURRED. (Formwlure of injury .n Pert 1 0• Pert II of Isom IBJ <br />0 ❑ ❑ ❑ <br />20c. TIME OF Hour Month Day <br />INJURY <br />201 INJURY OCCURRED IOe. PUCE OF INJURY (e.g., Inorabwthome,farm,factoy. 20f. CITY. TOWN, OR LOCATION COUNTY <br />a,reet, office bv.Id, q, sic.) STATE <br />❑ ❑ <br />21 �+ <br />�iby a *n; 1`1111 a M the deeeae.d (ran__ eC er L�igT�l�- -� <br />ceYOfle W -IV, ♦;Jf a. . 19 -- and let1` uv Ih. <br />«cum -- <br />22e. SIGNATURE ed e1.._ -- -- --- .. —_m, on the dab reefed ebo and 10 the barf o /__m ,LLno. led _(_rom tho cam. OaNd <br />h- s� ^''"' ..0 -- 1- 9— ort ;Ne) 226, ADDRESS 22e. DATE SIGNED <br />David K. Friedman, TS. D. 6303 South Park, Houston, Texas 7 ..6p <br />23a. BURIAL, CREMATION, REMOVAL (Specify) 236. DATE j 23c. NAME OF CEMETERY OR CREMAT <br />Removal 1 January 1, 1960 City C.."t' <br />23d. LOCATION (City, I—, or coon (St-f-) L - - - - -- - <br />hI b2A. FUNERAL DIRECTOR'S SIGNAT .� <br />Grand Island Nebraska P;1 H.FOU-1 &CO3t eyfa Jr. <br />I— R781 NO. 256. DATE RECD BY ICAL REGISTRAR <br />JAN. a. <br />1966 111, R'S T <br />If s' <br />
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