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I <br />h <br />()k' PUHLIC HEALTH, --LC VN NEBRASKA <br />1 EDUCATION AND WELFARE DEPARTMENT OF HEALTH <br />Bureau of Vital Statistics <br />BIRTH No. 128._...... CERTIFICATE OF DEATH STATE <br />i <br />1 <br />o> <br />• i `b <br />z° <br />N <br />C � <br />E a-4Y <br />j2 <br />I U <br />O 4 <br />1� <br />i <br />�E <br />E <br />E <br />Y <br />I� <br />T <br />z <br />G <br />I MACE YI DEAYx <br />0. COUNTY <br />............. .......... ........ <br />2. UtUAI IHtID[NC[(NAw.Rr.H I.W /),vul.l w.' R�rer,w Yd�r.MrwYnl <br />A urr�TOwe. DR �o�.non -- <br />STATE D. OUNTr' <br />IN,.: r"" .. inc" ter <br />C. LENGTH OF STAY IN IA <br />C. CITY, TOWN, OR LOCATION <br />e. NOM[ o /I no! In Anrpird, pnr errs! Odd—U, <br />H06PITal OR <br />d. STRF[T ADD [Ss <br />IxsTITUTIox <br />irrw ai'n:.e i3stial <br />r. IS PLACF OF pFAYN INSIDE CITY LIMITSr YES ® NO [] r. IS RESIDENCE YES YES <br />InSIOE CITY LIMITS' FARN RESIDENCE? <br />Y NAM[ OI No NO <br />DECEASED .Nidetr LaI( E. DATE m- A DRY Yr.F <br />(]yp or yrinr) MU _ 1le yr-int:ardt 4 11 1960 <br />DOEAT. <br />S SEX RACE T MARRIED ❑ Y DATE OF BIRTH "CUR S. <br />NEVER MARRIED ❑ 9 AGE lfn yrOr, B' UNDER N UA--- <br />Fe_.ma Ie " IRd bir(Adar) N UH <br />W—EDA2 Dlvoxcfp ' i); �'j% 1Jij� <br />4 <br />100 $UA[OCC rA Door IOD NIMDINESSORIMDUSTRY 11 BIRTNPLACF (.Vdr N111Yf <br />ii %rrfireo <br />i;;;� <br />Home aus,;ia U.S.A. <br />IL. FATHER 5 NAME <br />Jacob Trc'oeihorn <br />126. MOT MAIDEN NAME l0. N MF OF HUSBAND O I <br />Margaret Naib•_r;; <br />George (Deceased) <br />IS NAS DECEASED EV[P IF U 5 ARYCrORCESr <br />I r•.. ,...r .,... rr.. ,,...... CRUIES...I <br />16 SOCIAL SECURITY MO. IT INIDYMANT eaerr, <br />no xx <br />08 -2� -9528 Alex .1eil, Grand Island,�Ne'br. <br />O. CWR or MATH IER(n oXF1 oxe <ru,r pr fine /nr (•). (b). ­I (,),I <br />INTENYAL DRDEEN <br />PART I. MATH WAS CAUSED BY � <br />ONSET AND MATH <br />IMMEDIATE CAUSE (.1 <br />r <br />CoArl(ionY. rJlyto <br />TO ( <br />/, DUE b) _— W AIN <br />ASPA, pc NW (0)* _.._ <br />4.1 I_ IAN4 DUE TO Il)_ <br />Y <br />PART IL OTMFR SMiMIM'An COMgTIDNS CWfRNIRpi m LNATX EIIT NDT RFURD TO TMF 1FAY1 WL gSFAiE fOXgipx GIHX Ix IMT IIR) <br />- WAS AU Y <br />3 <br />PERFORNEm <br />YEs O NO ❑ <br />200 ACCIDENT SUIODF HOMIaCIDE <br />20b DESCRIBE HOW INJURY OCCURRED (En(er ndurr o /Injury in Part I or PRr( 11 o/Urn 11.) <br />2a TIME OF flour AflAt, DRy. Yrrr — <br />NIURY <br />Rle INJURY OCCURRED NIr. <br />PLACE OF IIUUNY (r, r.. IN P, AAONI AOMr, 101 CITY. TOWN. OR LOCATION COUNTY STAYS <br />WHILE AT 0 NOT WHILE /.— 1=1. A, of)Ire Udr.. WC.) <br />NORM AT WORD <br />11 . fRelOnd.d eh. n<c.a..d:rorr, ro rF ..di—RAW ti,m Oli.. on f <br />D..tN --d _ _ on fM dRN Olsf drko.r. —d fo eh, bR.f of ml knoWl.dgr. Erom fie RAMAH, Rt&gAT <br />12A t—TM[E prrr9r fbk) i0 A RESS 11t. DATE sIGN[0 <br />0-'4z' <br />13. h 3D OF 2 EOF CEMf TERM ON CREYATONY <br />LOCATION I C'UY. (OMn. O /county) 1&0X1 <br />4J14 95' I k Cem- Dry -- <br />Lincoln, Nebr. <br />N .Cr G ..N 25 S A }y [ 1 �1E NAYS OF NORTVARY <br />APR. s n o n wCiliL I .i <br />ADDRESS <br />t <br />LGS , <br />i <br />I <br />