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j <br />s <br />I <br />Issued May?, 1961 <br />PHS -7991 VS1 REV 4 -S7 STATE OF NEBRASKA <br />[i FARTmENT of PUBLIC HEALTH, DEPARTMENT OF HEALTH <br />EDUCATION AND WELFARE BNTIBau of Vital Statistics <br />BIRTH NO. 126........ CERTIFICATE OF DEATH STATE FILE NO.____._• _......_..--._-- <br />-I -0. OT OEATM 3....AL PEIIID A... w. - EMOE(W r. 11: -"-' e+. <br />.. COUNTY Hall . STATNebraska n. COUNTY Hall <br />A. CITY TOWN. ON LMATION LENOYM OE STAY IN IA r. CITY. TOWN. OR L-1111 <br />1 mi. East Grand Island <br />d. N if �« m Am -. p,,, and .dmr.0 d. STREET AOORESs <br />z <br />T -01 1 Mi. East Grand Island 1 Mi. East of Grand Island <br />4 <br />r. <br />15-PLICE or OEAT. iIS- CITY LIMITS YES [3 NO QL <br />1, IS RESIDENCE INSIDE CITY L711-ITS-1 YES /. TARN RESIDENCEr TES <br />NO MO <br />7 MAY[ Or �- _ _ Firtt .Vidd(e Lwt <br />1 DATE MonIA DEI Y.N. <br />•`n`D`A'[,:iNn M. PrestonFTHA <br />ril 14, 1960 <br />9 AGE l.. y..r, NUNOERIYCM INIO[RU MRS. <br />S Sf% <br />6 COLOR OR RACE <br />7 MARRIED® NEVER MARRIED El <br />E DATE Or BIRTH <br />F le <br />White <br />WIDOWED (-1 <br />2_28-1905 <br />/.d Airfw.r) Xw'M D.w May. AN, <br />55 <br />rd1 IOAWNIND Or BUSINESS OR INDUSTRY n. BIRTHPLACE (srae IF f.rean [.unirr) 12. <maN Or WIMr WIwERYr <br />10, <br />do lnl laROCgU %NOrt''rnp n /'nr.en4rAEa <br />Cook Reatuerant` Hutchinson, Kansas U. S. A. <br />IS.. fA,.,. "S NAME 131, MOTHER'S MAIDEN NAME 1A. NAMF 0r NUS[AND OR Wli[ <br />Isaac Davis Incinda Nicholas <br />E <br />IS WAS DECEASED EVER IN U S. AWNED FORCES, 16 SOCIAL SECURITY XO. 17 IMr�WMAMT AMrM1 <br />d - <br />T" '�fo . "` °' ". ' " ° Earl Preston( Grand Island( Nebraska <br />IE. [AN[[ OP ORATM 1Ean anlr "M raw D.r ia. /Nr (a). (D), do.) .. 1MTERMK <br />ONSET AIO n <br />SIE J <br />PART I. DEATH WASATE <br />O <br />CA <br />IMMEDIATE CAVSE 111 <br />C.nliri.nA. , I. 1 OUE TO (D) <br />O <br />NCR p . .It jo <br />AIONAM <br />♦/Ird'rlsuX I.,1. DUE TO (r) _ <br />t <br />ART II OTMG SIEIXIINa11 CONCITIONS C)NMNUTRM TO MTN M NOT RELATE) TD THE TEANIXAL DISUSE COMBAT EN OVER W PMT 1(4) IRAs <br />PERFORMED? <br />" <br />3 YES 0 AND IIO LJ- <br />Ills ACCIDENT SUICIDE IIONICIOF 2fID DESCRIBE NOW INJURY OCCURRED (Enitr ndurr .Jinfurl in Y.rl l.r Pal 11 .f DVa 1E.) <br />Ky ❑ ❑ ❑ <br />Ca <br />" .l <br />� � IN1UROr N.ur M.NfA, Dar, Yen <br />AN <br />i 20M INJURY OCCURRED M4 PLACE Or INIUAY (t... M N AINNM AAAW. E)/ CITY. TOWN. OR LOCATION COUNTY STATE <br />:Hat AT ❑ MOT MILE ❑ fors. IXl.rr. - d,.ArC Ndd.. NY ) <br />WOAN AT .AN <br />II .ndla,l uWlir. <br />I.ENnd.drh.d.c....d/rom <br />Da.YA x MYTad.t.� -- nth. d.N .t.t.d.DOr. .nd to tA. D..t o/ mY knawM1dd.. Erom tAR e.MERE .fatal. <br />3.. [IOMATU (DJE'a .r f11r) 27D AD 5 221. OA WNFO <br />V <br />J . TE 27 NAME Jr CIMETERY OR CREMATORY 23d LOCATION(CRI.I.Mn,.rr.u.lr) &AF' <br />23. RAMR CRUAVION. <br />,L sDEn•n ! 16' 6p Island Cemete Grand Island. Nebraska <br />Bur+a� 1- - <br />_Grand <br />N. OAT[ RECD. BY AEI.Ii rRAN IiS. REOISTRAA'S SMiHATWIC � U. MANE OF MORTUARY ADDRESS <br />Livingston- Sondermann Grand Island. Nebr. ' <br />Issued May?, 1961 <br />