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s� <br />PHS- 798(VS) REV. 4 -57 W STATE OF NEBRASKA ' <br />DEPARTMENT OF PUBLIC HEALTH, <br />x EDUCATION AND WELFARE DEPARTMENT OF HEALTH <br />Bureau of Vital Statistics -,411 <br />a BIRTH NO. 126-- - - - --- CERTIFICATE OF DEAT#' STATE FILE <br />F <br />U <br />X <br />w <br />'c1 <br />v <br />z" o <br />J] z <br />u <br />x0 <br />v <br />F.I a u <br />�w a <br />eti C Q <br />r-ell .7 a � <br />ah we <br />0 <br />�wE <br />3� ov <br />�d 4 %C <br />Z?Sx� <br />Aoc3M <br />9 <br />O <br />asO i.y J= <br />R <br />(:1 0 <br />q u O.o <br />Q'^ U <br />7 C Q A <br />UJ ^ C y <br />4E� <br />">O M <br />�+ 0 <br />O C M <br />wo a <br />0 <br />w <br />va u <br />G� n <br />ro u <br />£O w <br />W p <br />a <br />u <br />roC u <br />�« u <br />z <br />I. PLACE OF DEATH <br />2. USUAL RESIDENCE(WAered— ,diised. Ilieslituhm: Resils.erbcf— adwissien) <br />a. COUNTY Hal <br />Hall <br />a. STATE N ebr b. COUNTY <br />Hall <br />b. CITY, TOWN. OR LOCATION <br />C. LENGTH OF STAY IN lb <br />C. CITY. TOWN, OR LOCATION <br />Grand Island <br />38 yes <br />Grand Island, Nebr. <br />d. NAME OF (If not in hospital, give street address) <br />_ <br />d. STREET ADDRESS <br />HOSPITAL OR <br />INSTITUTION St. Francis Hosni +.al <br />521x. N. Lambert <br />t. IS PLACE OF DEATH INSIDE CITY LIMITS? YES =NO❑ <br />I. IS RESIDENCE INSIDE CITY LIMITS? YES <br />J. FARM RESIDENCE? YES — <br />NO � <br />NO <br />3 NAME OF First Middle Last <br />DECEASED <br />4. DATE Month Day Year m <br />(Type or print) Raymond E. Larsen <br />DEATH 4- 2f?-59 . <br />S. SEX <br />6 COLOR OR RACE <br />7 MARRIED NEVER MARRIED ❑ <br />8 DATE OF BIRTH <br />9. AGE (In years <br />IF UNDER I YEAR <br />UNDER 24 WIS. <br />M- As <br />Dale <br />Hews <br />M <br />1 <br />Saj <br />6-16--11 <br />las(l yl-ay) <br />WIDOWED ❑ DIVORCED <br />(,I,�7 <br />10a. USUAL OCCUPATION (Give kind of work done <br />10b. KINDOF BUSINESSOR INDUSTRY <br />11. BIRTHPLACE (Stale or foreign country) <br />12. CITIZEN OF WHAT COUNTRY? <br />during most of working life, even if retired) <br />Laborer <br />Nur sere <br />Howard Countv Nebr. <br />USA <br />13a. FATHERS NAME <br />13b. MOTHER'S MAIDEN NAME 14. <br />_ <br />NAME OF HUSBAND OR WIFE <br />Thomas Larsen <br />I'ar- Nielsen <br />Mrs. Ina Larsen <br />15 WAS DECEASED EVER <br />IN U S. ARMED FORCES? <br />16 SOCIAL SECURITY <br />I NFORMANT Address <br />( Yrs. no. or —knou,n� <br />i!1 V.a. o, c, ua. or dale of urs) <br />no <br />506- C�9 -b217rs. <br />Ina Larsen Grand Island. Nebr. <br />18. CAUSE OF DEATH [Enter only one cause per line for (a), (b), and (0.1 <br />_ <br />INTERVAL BETWEEN <br />PART I. DEATH WAS CAUSED BY <br />IMMEDIATE CAUSE (o) -_ Carcinoma. o .F+ lung vdth metastatic lesions <br />ONSET AND DEATH <br />_ <br />Conditions, r /any. DUE TO (b) <br />which are <br />abote cause (aL <br />2 <br />stating the u nder- <br />lying cause last. DUE TO (c) <br />1 <br />— <br />0 <br />PART 11. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE CONDITION GIVEN IN PART 1(4) <br />M WAS AUTOPSY <br />PERFORMED? <br />YES ❑ NO ❑ <br />20a ACCIDENT SUICIDE HOMICIDE <br />20b DESCRIBE HOW INJURY OCCURRED. (Enter nature ofinjury in Part l or Part 11ofitem 18.) <br />ar <br />u <br />❑ ❑ ❑ <br />< <br />20C TIME OF !lour Month, Day, Year <br />U <br />INJURY a. M. <br />D <br />P. M. <br />f <br />20d INJURY OCCURRED <br />20e. PLACE OF INJURY (e. q., in or about home, <br />20f. CITY. TOWN, OR LOCATION COUNTY STATE <br />WHILE AT C] NOT WHILE [3 <br />farm, factory, street, office bldg., dc.) <br />WORK AT WORK <br />21 /attended the deceased from to and last saw her alive on <br />him <br />Death occurred at m on the date stated above; and to the best of my knowledge, from the causes stated. <br />22a SIGNATURE (Degree or title) <br />22b ADDRESS <br />22t. DATE SIGNED <br />Leo �.. Adams, M. D. <br />Grand Island, Nebr. <br />23a BURIAL. CREMATION. 23b DATE 23C NAME OF CEMETERY OR CREMATORY 23d. LOCATION (City, town. or county) (State) <br />REMOVAL (.ti c.fyl I <br />_ - Bu_ rial - - L_1� -_ 9 - -- -�a?' rrand I 1 an d, Nebr- <br />24. DATE RECD. BY REGISTRAR 25. REGISTRAR'S SIGNATURE 26. N M ARY D 5 <br />u4edO c�es MOR �uneral Home, Grand �s�land. j�ebr. <br />s� <br />o V <br />i < <br />y <br />`71 <br />C � <br />