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NNW= <br />PHS-798(VS) REV, 4-57 STATE OF NEBRASKA. <br />DEPARTMENT OF PUBLIC HEALTH, <br />EDUCATION AND WELFARE DEPARTMENT OF HEALTH Cj�o*p*y <br />Bureau of Vital Statistics <br />COPY <br />BIRTH NO. 126_______ CERTIFICATE OF DEATH, STATE FILE NO ................................. ........................ <br />1. PLACE OF DEATH 2. USUAL RESIDENCE (Wher. d-.d Iid. Iti-tihtsi- Rsaidaus W­ <br />a. COUNTY a. STATE D. COUNT <br />Hall Nebr. kal-1 <br />b, CITY. TOWN, OR LOCATION c. LENGTH OF STAY IN lb C. CITY, TOWN, OR LOCATION <br />Grand Island- 41 yrs Grand Island, Nebr. <br />o2i <br />d. NAME OF (if not in hospital, give street address) d. STREET ADDRESS <br />HOSPITAL OR ' <br />IN z INSTITUTION Sunny Side Rest Home 242 So. Fine St. <br />0 <br />e. IS PLACE OF DEATH INSIDE CITY LIMITS? YESIP No 0 <br />c. IS RESIDENCE INSIDE CITY LIMITS? YES <br />f, FARM RESIDENCE? YES <br />0 r <br />0 <br />NOO <br />NO <br />FI.Z <br />3. NAME <br />a <br />Of First Middle Last <br />DECEASED <br />4. DATE month Day Year <br />OF <br />W <br />0 Q <br />(Type or print) B. <br />Clara Von Ohlen <br />DEATH March 1, 1960 <br />- <br />5. SEX <br />6. COLOR OR RACE <br />7. MARRIED ❑ NEVER MARRIED ❑ <br />B. DATE OF BIRTH <br />9. AGE (In years <br />IF UNDER I YEAR <br />DF UNDER 24 HRS. <br />'jw� <br />if. <br />;ry ;I Q)i <br />Female <br />White <br />WIDOWEDS DIVORCED 0 <br />Aug. 25, 1568 <br />140 birthday) <br />91 <br />10a, USUAL OCCUPATION (Give kind of work done <br />7 most,;tp king life, even if retired) <br />105. KIND OF BUSINESS OR INDUSTRY <br />11. BIRTHPLACE (State or foreign country) <br />M CITIZEN OF WHAT COUNTRY? <br />0 .! <br />f?� Use 1fe <br />House keeving <br />Hohenstein, Germanv <br />'U.S.A. <br />rA 1 .11. <br />[.4 ' q'i C:� i <br />13a. FATHER'S NAME <br />13b.MOTHER'S MAIDEN NAME 14. <br />NAME OF HUSBAND OR WIFE <br />Q b <br />Julius Grosch <br />Bertha Vogel <br />Henry Von Chlen <br />om E O <br />15. WAS DECEASED <br />SED EVER <br />S. <br />IN U S ARMED FORCES? <br />. <br />16 SOCIAL SECURITY NO. <br />Address <br />17.. INFORMANT <br />"Z r t> i <br />;4.0 cd: <br />or unknorenl <br />f Y,. g,,e dales f -w) <br />- <br />- <br />1 <br />Re H. Von Ohlen Grand Island, Nebr. <br />18. CAUSE Of D-ATH (Enter only one cause per line for (a), (b), and (0.1 <br />INTERVAL BETWEEN <br />tr :S <br />ca : <br />04 <br />'_ a) i <br />Z - C�' a <br />PART I. DEATH WAS CAUSED BY: -rhage <br />Cerebral Hemo, <br />ONSET AND DEATH <br />.0 <br />IMMEDIATE CAUSE (a <br />ai 0-0, <br />Conditions, if any. DUE TO (b) <br />which to <br />0 <br />gave ri <br />above cause It.). <br />I <br />=,,,a X <br />U.- , <br />(1) 0 <br />U.0 <br />stating the cause under- <br />ly ing last. DUE TO (c) <br />> <br />2 <br />PART If. OTHER SIGNIFICANT CONDITIONS COMM19WING TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE CONDITION GIVEN IN PART )(4) <br />19. WAS AUTOPSY <br />PERFORMED? <br />YES ❑ NO ❑ <br />-0 <br />20a. ACCIDENT SUICIDE HOMICIDE <br />20b. DESCRIBE HOW INJURY OCCURRED. (Enter nature of injury in Part I or Part 11 of item 18.) <br />cr <br />W <br />❑ ❑ El <br />> <br />20c, TIME OF Hour Month, Day, Year <br />INJURY a. M. <br />N <br />P.m. <br />v 0 0 <br />E <br />:E <br />20d. INJURY OCCURRED <br />20e. PLACE OF INJURY (e. g., in or about A <br />farm,fiad ory, street, bldg., <br />20f CITY, TOWN, OR LOCATION COUNTY STATE <br />01 , I <br />WHILE AT ❑ NOT WHILE C] <br />El <br />office see <br />WORK AT WORK <br />21. 1 attended the deceased from her alive on to and last saw him <br />Cd 0 U <br />E >' <br />I <br />. -. 'z <br />Death occurred at m on the date stated above; and to the beat of my knowledie, from the causes stated. <br />22a. SIGNATURE (Degree or title) <br />22b. ADDRESS <br />22e. DATE SIGNED <br />Leo Adams D. <br />Grand Island, Nebr. <br />3-3 -60 <br />231. BURIAL. CREMATION, <br />23b. DATE <br />123c. NAME OF CEMETERY OR CREMATORY <br />23d. LOCATION (City, town. or county) (State) <br />E. h W <br />3 -4 -60 <br />Grand Island Cemetery <br />1sland. <br />ro <br />Grand Nebraska <br />24. DATE RECD. BY REGISTRAR <br />25. REGISTRAR'S SIGNATURE <br />26. NAME OF MORJUARY ADDRESS <br />Arfel-Bu's Ierlejfts Funal Home <br />Gran s and, Nebr. <br />State of Nlcbraska ss <br />C.Qulity Of 1-Y <br />ur <br />nelical index and filed <br />fol 3�egister of <br />Gffice of I <br />day of <br />C'n .�o�z __ --- <br />at <br />minu�ts L M <br />0 of <br />L-11 in 0-j- -------- <br />P­;Cl 1�_CG r a <br />at page --- <br />--- ---- ee d-- <br />--- - s <br />- <br />By <br />Deputy <br />Fees <br />4b -4- . <br />