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19 <br />PHS- 796(VS) REV. 7 -63 STATE OF NEBRASKA <br />DEPARTMENT OF PUBLIC HEALTH, DEPARTMENT OF HEALTH <br />EDUCATION AND WELFARE Bur of Vital StR1,1a115A <br />BIRTH NO. 126 CERTIFICATE OF DEATH srnTk: en,E No. <br />1. PLACE. OF DEATH <br />- - - - =. USUAL RESIDENCE E I Whc d Bused It. ed S( s.Itutl m d ce <br />a COUNTY f1 e. STATE I b COUNTY I llbefo <br />b. CITY (If at, id, .Iplllw 11 1 . write Ru 1) r. L F, N G T H OF I�a, CITY (If outs d ..w 1 a, write RURAL) <br />OR STAY OR <br />,• __TOw(�rh._l:<1 :Cr &.r_ <br />TOWN <br />d FULL NAME OF (if ao, ta h aptnl o lion, It —C d. STREET (If I -- <br />HOSTIT\I 1 OR ld ADDRESS ac I tion) <br />2 INSTITUTION 1.11tt" e 1 Ho 7 Wert h <br />a,tl <br />3 NAME OF (First) b (Middle) 4 D1TL (M t) ID Y) (Y ar) 'IF DECEASED <br />(T r or Pry [) lily i$ r.11 L1 �',ilt'y 1 EATF[ c .5. 1356 - <br />f -. _ ... _.. .. _....... .. _ -, <br />II S. SEX �6. COLOR or RACE 7. MARRIED, NEVER MARRIED, 3. DATE OF BIRTH 9. AGE (la y ' If Cats, 1 Y1. It U &, 24 H I. <br />WIDOWED, DIVORCED (Spacify)I last birthday)! Mo 1 H <br />7E I WIXIOW's4 - ___i�yv. __1:!- istP _ 78 a 18 n. <br />'f 19 USUAL OCCDPATION (C k d t k 106•�CIND�_QpFF BIISIN£ S3 I] BIRTH (C ty t n [) (St t 1 CITIZEN OF WHAT <br />do d 1 oat f king life. van If retired) Cz `./ :JLRt�t3l"5m +, PLACE foreign country) COUNTRY. <br />! _. F A n�- So�eme}n :2 i-R -+ik�} L�}, - <br />- -'. <br />19. FATHER'S NAME ' e. ^s ids. MO HER'S MAIDEN NAME �. ]db. NAME OF HUSBAND OR WIFE ' <br />- <br />Jctlrn_D, �trr.De1l Kel-lo fuar�_33iley__ <br />t WAS DE u.k.._ ((I, e! g ewer RMED o RCES�) 16. SOCIAL S CURNo, 17 INFORMANTS NAME o S gnature &Address or Y °Y \c <br />NX dary Bitiiey Grand 1slRnd <br />E .I <br />y CAUSE (, o , ) MEDICAL CERTIFICATION Or <br />E" <br />e far".) )and I. DISEASE OR CONDITION <br />LEADING O DEATH- e <br />ANTECEDENCAUSES Thl d th tel Be <br />:_L:��... .. ........� <br />ffi <br />g M.611 e to the above < DO B -H -- -- - - -- <br />I est fulore, th i ... dittone - <br />ete It the undererlaantr but I to a DUE TO ( ) th, eu<, Inlury. or II ,not ' <br />tb f mefeg) thI hdl I` OTHER SICN'FICAe T CONDITIONS DIA bat 0 III. <br />V <br />hl h ua d d th <br />.• <br />rels N io the dillaoI a, ronditlo Ina death. � <br />19e. DATE OF OPERA 196. MAJOR FINDINGS OF OPERATION 20. AUTOPSY? ± <br />V TION' <br />F -- _ -... __ _. .. <br />_- Ye No V <br />21.. ACCIDENT (Specify) 216 PLACE OF INJURY ( r about 21 a.fCITY OR TOWN) (COUNTY) (STATE <br />SUICIDE 'home, farm f story, .treat ff ce ibldg., Or.)l (If oral area write RURAL) <br />HOMICIDE r <br />�t Pld. TTOME (M t) (Day) (Year) (Hour) 21 e. INJURY OCCIJRR❑EI 21L HOW DID INJURY OCCUR? - <br />1 Whde t W rk <br />INJURY Not Wh 1 at Work E] - -_- <br />�_._. <br />22 I hereby certify that I ttend the deceased f om �.....d. IB-5 ggglto1� '.� I9c _{q that I fast aa. the de- <br />IF <br />23.. Ceased ' s nxoRE On��L)ttI(Ueeaee oo ucurred an from the causes and _on . the _da4�D�¢te� above. <br />' <br />h' 1 21. BURIAL 246. PATE 14c. NAME F C ERY OR CREMATORY 24d. LOCATION (Cty t uvtyy)) (State) <br />CREMATION 0 i <br />REMOVAL speHr> Dec 8/5 Gr d island Cam- er Grand <br />island, "ebr <br />a II{II <br />DATE RECD BY LOCAL REI:1'sAµ'e �F_U I CTOR'S SIG�,RE {�ADUR f /� <br />I nrn 17- 1Qt4'y►''G•� -) - -- -AAA ..ifi! /.w__.L1iAii//%YLItl1/' <br />Issued December 19, 1956 <br />a <br />_411 <br />