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PHSY798(VS) REV. ]- 3 STATE OF NEBRASKA <br />DEPARTMENT OF D PUBLIC HEALTH. DEPARTMENT OF HEALTH 0/'t0(� <br />� <br />EDUCATION AND WELFARE gayeau of Vital SiBtlstit� � 5"tidl ,l V 3 <br />BIRTH NO. 126...._. CERTIFICATE OF DEATH STATE FILE NO <br />}. PLACE OF DEATH USUAL RESIDENCE (Wh re deceased i ved. /f in tit tl residence <br />COUNTY Bela a. STATE <br />b. COg1s1C bet .amla.lon). <br />t,i& rolrpolr limits, writ R U c. L E N GvT H OF CITY (If .—Id, e,�o r.te 1 t . writ RURAL) <br />Q' b TOIVNtf Shelton -.. -.. <br />STAY OR 1� - TOWN._ - WlQy____ <br />d. FULL NAME OF (If t in hoaoltel or tnatitutioln, tree d. STREET (if rural. 'e location) <br />R e e <br />o. HOSPITAL OR 2>}} address) ADDRESS <br />Z INSTITUTION- ____- �.tt__R9D19. -. <br />- -_— __ <br />3. NAME OF e. IFi st) -------- - - - -b. (Middle) e. -(Le tl - - -- C. DATE (Month) (Day) (Year) <br />n DECEASED OF <br />$ ij i w.. w DEATH <br />l Y� <br />5. SEX ' 6. COLOR or RACE.?. MARRIED, NEVER MARRIED, j 8. DATE OF BIRTH 9 AGE (In yre. It Under I Yr It Under 2e Hre. <br />WIDOWED, DIVORCED (Spc uy)i last in thday) Moe. Daye Houre Mn. <br />11h1te ! rriid _. ___1JRtL2a`,Z_1nQ[3NLS�� -- <br />g 10 USUAL OCCUPATION�I+ItG kind of w k106. KIND OF BUSINESS 11. BIRTH- (City. town c only) (State 12, CITIZEN OF WHAT <br />.i ', done during mkt ^`tire e•even i( retired) OR INDUSTRY PLACE torelgno ovntry) CO NTRY? <br />< c� I ITT_ Farmim ! She1tTN�D.r� 1 II. 2. - <br />'� 13. FATHER'S NAME <br />lEa. MOTHER'S MAIDEN NAME ICb. NAME OF HUSBAND OR WIFE <br />J F ieraldo l¢era -- <br />'p' 16. WAS DECEASED EVER IN U. S. ARMa D�FORCEStteJ 16. SOCIAL SECURITY Il IN ORMANT'S NAME or SI¢nature k Address <br />Ifl 'A <br />e (Yee, n unknown (It yea, �vOe war or s o aervt BO NO. <br />m o, or <br />°x ! 18 CAUSE OF DEATN� MEDICAL CEETIFICA N Intend B.t , <br />0x °e E to 1 DISEASE OR CONDITION Otwt and D..lh <br />'.j I DIRECTLY LEADING TO DEATH• ' 1 5' �,� <br />I1 for le), (b). <br />u <br />nm hie. 1 Ittdmere., iheh dia <br />C Thls don nat mean tbe'�, ANTECEDENT CAUSES <br />D <br />-gym ................................. .. <br />DUE TO ( b) .................................................................. ........................_...... <br />,.yr i Morbid eonditiona. I( an >, ¢Ivin¢ <br />W.ry, or lot• DUE TO I <br />rompllea-r... e I rise to the above mole la) atatin¢ _ <br />< 4I. used d<aN.nderl>Ing (0­ ..... ......... ...... -..... ....... ....................... <br />Alan which <br />- lI OTHER SIGNIFICANT CONDITIONS - <br />g - P i ✓' Londltions nn tributin¢ to the d th bat not <br />rdabd to the dlnsre or —did.. eaudn. death. <br />�M T MAJOR - - _-. 20. AUTOPSY? _ <br />TIoN <br />! p 18.. DATE OF OPERA- 196 MAJOR FINDINGS OF OPERATION <br />Yee No _ <br />F <br />21.. ACCIDENT (Spa tY) 21b. PLACE OF INJURY ( .. i bo tT 21 (CITY OR TOWN) (COUNTY) (STATE) <br />ESUICIDE 'h me. farm. factory t ffito bldg ) IIf ral eme write RURAL)' <br />L HOhfICIDF. _ - <br />e 6 9 21d. TIMFE (Month) (Dar) (Year) (Hourl', 21 INJURY OCCURRED 1 ?It. HOW DID INJURY OCCUR? <br />a While t Work <br />g INJURY m Not While at W k� -- <br />'.o g '. <br />22.1 — ceased atcerto „y thnt 1 ttexded the d <br />death ",ed 36. ADDRESS to . o the ca a land o that d ate Bate the above. <br />5 m Jrom the cattaea and Ott the date stated above. <br />y 28a. SIGN. CI RI. f s p 28c. DATE 91CNED <br />(Degree or ° < 2e B jRISI. t -- - 1 2eb DA'C 2 i Nit MECERY OR CREMATORY Zed. L (City. ton, or r 3 t 8 te) <br />"REY T � Ll Y A7✓ <br />_ <br />D'1 C'.ECD L Y LOCA A'. UF.E 25. FUNE L OR'S SIGNATURE <br />A 8 <br />AECL R I . /�.s' v <br />0 <br />#t <br />Issued April 11, 1960 <br />d a-sa <br />I <br />I <br />