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+h�l +,l D11VIh y.'- t i.3 <br />s �a <br />fo <br />c IS PLACE OF EA7H li(SI E CI YWLI ZITS Y a as} ° t ( <br />ra'r1S R>ESIDENGE INSIDE GI Y LIMITST, , <br />f IS RESIDENCE ON `A. FARMt <br />' YES y'NO„❑ ""`" <br />YES't#O ❑ <br />YES ❑, ' • NO -c7 , <br />3. NAME OF tYrat Mldd2t„ Leal <br />4. DATE MontA Day YtW J'' <br />` DECEAS.ED <br />(Type or prim) aV�' <br />DF <br />DEATH <br />5. SEX D <br />6.'COLOR`OR' RACE `:` <br />7: MARRIED (� NEVER MARRIED ❑ <br />6.DATE OF BIRTH <br />9 AGE (In pears <br />IF UNDER YEAR <br />IF VN5bM1 2l NRS. <br />Al.a. <br />Dew <br />Hover Ma+ <br />Male f <br />White <br />WIDOWED C1 DIVORCED El <br />load birthday) <br />10a. USUAL OCCpPATION (Give kind of work done <br />ob. KIND OF BUSINESS OR INDUSTRY <br />11, BIRTHPLACE (State or foreign country) <br />12.' CITIZEN OF p%JNTRYT, <br />during . most of working till, even if retired) <br />'WHAT <br />Barber' <br />Barber <br />Washin on Kansas <br />A, <br />13a. FATHERS NAME. - <br />13b. MOTHER'S: MAIDEN RAME -' 14. <br />:NAME'OF'.HUSBAND OR WIFE <br />Elias J.Whetstine <br />Ada McCrea <br />iv .C) e <br />15 WpS DEC EgSED EVER <br />IN. U.S. ARMED FORCES? <br />16. SOCIAL SECURITY No. <br />17 INFORMANT Address <br />(Y <s, nn unkno) <br />um <br />(! Vea oia< ua or data nlamue) <br />fl <br />" <br />vest <br />17- 8/1 <br />0721,1 91 <br />Mrs. ViVa 'w <br />IB. CAUSE OF DEATH [Enter only one cause per line far.(d)(b), and (c).] <br />INTERVAL. BETWEEN <br />PART I. DEATH WAS CAUSED BY: t�g <br />Arteriosclerotic -alt <br />ONSETAND'DEATH , <br />IMMEDIATE CAUSE (a) i7 dT S -asp jdt}1 RAl('l fi Pa <br />arot-ic value <br />Conditions, iJany, DUE TO (b), Gene <br />which gave eraff to <br />— <br />above cause (o), <br />} <br />z <br />stating the under- <br />.lying cause last. DUE TO (c); <br />0 <br />PART II. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH. BUT NOT RELATED TO THE TERMINAL DISEASE CONDITION GIVEN. IN PART 1(a) <br />19. WAS AUTOPSY <br />¢ <br />- - <br />PERFORMED? <br />U <br />YES NO .. <br />+—` <br />F <br />20a. ACCIDENT SUICIDE HOMICIDE <br />206. DESCRIBE HOW INJURY OCCURRED (Enter nature oJ+njury -in Part / of Part 11 of item It+.) <br />W <br />U <br />❑ - ❑. ❑. <br />a <br />20c. TIME OF .Flour Mouth, Day, Year <br />- - - —� <br />U <br />INJURY a. M. <br />W <br />i <br />20d. INJURY OCCURRED <br />20e..PLACE OF INJURY (e. g., in or about home, <br />20J. CITY. TOWN. OR LOCATION COUNTY STATE <br />WHILE AT ❑ NOT WHILE ❑ <br />' farm, factory, street, office bldg., etc.). <br />WORK AT WORK <br />21 ? attended the deceased from to and /a at saw: ti�m;a1&& on <br />Dee th occurred at m on the date stated above; and to the best, of my knowledge, from the causes stated.,, <br />22a. f10NATURE (peprle or title) <br />22b. ADDRESS <br />22c. DATE SIGNED ' <br />1 obert F. Munch M.D,. <br />Vets. hos 'ital Grand Island <br />23a. BURIAL; CREMATION, <br />23b, DATE 23c NAME OF CEMETERY OR CREMATORY <br />23d. LOCATION (City, Lawn. or county) (Slate) <br />Mgalpecif) <br />12/10/59 West Lawn Memorial Park <br />1 ind,r Nebraska <br />24. DATE RECD. BY REGISTRAR < <br />25 REGISTRARS SIGNATURE 6. U R DI TOR ADDRESS <br />=uer— <br />pe Geddes ,Grand 'Ts1 A`nd : NPh�_ <br />