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lk <br />5. SEX Id. COLOR or RACEr7. <br />1 <br />PHS- ?es(VS) REV.? -68 <br />1 DEPARTMENT OF PUBLIC HEALTH. <br />EDUCATION AND WELFARE <br />STATE OF NEBRASKA 004831 <br />DEPARTMENT OF HEALTH 1 <br />It Vnder 1 Yr. <br />p{os. ppyp <br />k <br />III <br />Bureau Of Vital Statistica , <br />Married ___y 10 -6 -02 _ <br />` <br />BIRTH NO 126 __ <br />CERTIFICATE OF DEATH STATE FILE No ......_... <br />-ids <br />L_ <br />1. OF DEATH - - -- <br />- - -- <br />12. USUAL RESIDENCE (Wh re d-- eceased 11 ed Ifin it tl <br />done daring moat o! working Ilfe, even if retiredl'. OR INDUSTRY <br />p <br />a. COUNTY <br />�.' Hall <br />Z - + <br />Ilia STATE b. COUNTY before ad iael ) <br />Nebraska Hall -- <br />_ <br />tia. MOTHER'S MAIDEN NAME 1 lib. <br />- <br />b. CITY (If outcida mrpo 11 Ste. wri R I) L E N G T H OF <br />— --- --__ <br />c. CITY (It ta,d. corpo 1 s. RURAL) <br />Komar <br />TOWNGrand lSland <br />'STAYlO � <br />OR <br />TOWN Grand Island — ___- .- -. - - -- <br />Yee -2 - 2 to 8 -28-/3 Unknown__ -- VA Hospital Records <br />' d FULL NAME OF (If not in hoeD t I metltut 1 e etr <br />I HOSPITAL OR dres <br />1 x INS UTION Veterans _Administr_ation F ospij�al <br />I STREET (I! rural. grve location) <br />ADDRESS <br />20$ Tenth Street <br />_ - <br />Y 9. NAME OF a. (first) <br />-- <br />b (Middle) <br />_ -East <br />c- lLa +t1 - - - --� ---Don -- <br />DATE (M .nth) (Day) (Year) <br />C DECEASED <br />or Print) AUGUST <br />�i. <br />(NEST)_ 2II.AVY HEATH �- - <br />lk <br />5. SEX Id. COLOR or RACEr7. <br />1 <br />I <br />r <br />9. AGE (In yre. <br />Iaet birthday) <br />It Vnder 1 Yr. <br />p{os. ppyp <br />If Undsr 1i Hre. <br />ftoure Min. <br />Male Yihite <br />Married ___y 10 -6 -02 _ <br />pk <br />M <br />bb LH <br />L_ <br />lk <br />5. SEX Id. COLOR or RACEr7. <br />1 <br />MARRIED, NEVER MARRIED, 8. DATE OF BIRTH <br />WIDOWED, DIVORCED (Sce Ify)j <br />9. AGE (In yre. <br />Iaet birthday) <br />It Vnder 1 Yr. <br />p{os. ppyp <br />If Undsr 1i Hre. <br />ftoure Min. <br />Male Yihite <br />Married ___y 10 -6 -02 _ <br />1 s. <br />bb LH <br />L_ <br />IOa. USUAL OCCUPATION (Give kind of w k 106. KIND OF BUSINESS tl. <br />BIRTH- (City, town or county) (State <br />12. CITIZEN OF WHAT <br />done daring moat o! working Ilfe, even if retiredl'. OR INDUSTRY <br />p <br />PLACE foreign untry) <br />ht .ado, Ti1i.,ota <br />COUNTRY? <br />U.S.A. -- <br />le. FATHER'S NAME <br />_ <br />tia. MOTHER'S MAIDEN NAME 1 lib. <br />NAME OF HUSBAND OR WIFE <br />P <br />Komar <br />Mildred Pitke Zilaw <br />16. WAS DECE SSMEi ER IN U. S. ARMED FORCES? 16. SOCIAL SECURITY 12. INFORMANT'S NAME or Signature Addreu <br />(Yu, no, w un (It Y.s, give war or d.ke of service) NO. <br />Yee -2 - 2 to 8 -28-/3 Unknown__ -- VA Hospital Records <br />19. CAUSE DEATH <br />MEDICAL CERTIFICATION <br />B.Be. <br />a <br />Enter only one uux cerl <br />DISEASE OR CONDITION <br />('DIRECTLY <br />0-1 <br />Ogaat sad Dead <br />u a ter (a). ib)..na (0 <br />LEADING TO DEATH - <br />( a).... TUMor ....of...larymx...oS._uaadate ed., <br />histological type <br />'This dew net mean th< <br />dslnb neh u <br />CAUSES <br />DUE TO (b)._............__._. _"'.___...__.......'.'......__ .. ......................._......_ ...................... <br />maNa/ <br />butt <br />� aa: <br />ten ditlo If . tivins <br />It a-. <br />ew, /Nary,asr rsrapilea- <br />.used dent► <br />LANTECEDENT <br />I. a (n) al.ting <br />the aw►ki <br />erlying race lut. DUE TO (c)..__. ............._._.. <br />1 <br />II. OTHER SIGNIFICANT CONDITIONS Tumor of pituitary gland, <br />3 <br />Condition. rontrftf.g to the death bot not <br />din t roe dlaaaae er ro.dill.. r.a.ingg_ d._.d_.__typ_e_undetermined _ <br />Unknown <br />lea. DATE OF OPERA- <br />19b. MAJOR FINDINGS OF OPERATION <br />20. P9 Y7 <br />TION <br />- - - - - - - <br />- - - - - - - - - - - - --- - - - - - - - - - - <br />23a. ACCIDENT (Specify) 21b. <br />PLACE OF INJURY (e.g.. In r about <br />." <br />21c (CITY OR TOWN) (COUNTY) (STATE) <br />IIf area, write RURAL) <br />SUICIDE : .-' <br />- MOMIDEF- - - - - <br />"". c street, .(fife bldg., etc.) <br />(a'.. <br />- - - - - - - - - - - <br />rural <br />_. - - - — — - - - - - - - - <br />Its. TIME (Month) (Day) (Year) (Hour) 21e. INJURY OCCURRED 21f, HOW DID INJURY OCCUR? <br />While at Work <br />- RRL' - - - - ,jJor- Wjile -at W�kO - - - - - - - - - - - - -, - - - - - <br />22.1 hereby certify that / attended the deceased Jrom ...... i'..:.r7..., to......ir..-.5?.'......., 19..ri4, <br />and that death occurred atlZ:2O h., from the catwes and on the date stated above. <br />28a. SI - - -� -- (Degree or Utk) -296. ADDRESS �- 2Y<. DATE 9ICNED <br />(_ ',;, iSdre_ i.D.LFatholo i t VA Hos ital Grand Island Ne r. -'- <br />Yis. BURIAL i�..^PTE T2:.. NAME OF CEMETERY OR CREMA I lid. LOCATION (City, town, or tounty) (State) <br />CREMAT ?ON (? I 10,13$4 kcacla Cemet"7 �i �I oago. j e <br />3 REM.- I Spe.:iiy l- "''r T „ _ n_ e <br />. 3ts- <br />11 <br />V <br />