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41- <br />DEPAR IVI REV 4-57 <br />U STATE OF NEBRASKA <br />rry(}l+ I DEPARTION OF PELFA HEALTH. <br />EDUCATION AND wFLFAAE DEPARTMENT OF HEALTH <br />Bureau of Vital Statistics <br />BIRTH No 126 .... CERTIFICATE OF DEATH STATE FILE No. J 9 - U 167 <br />1 <br />lZ' <br />.J <br />i <br />I. PLACE 01 DEATH <br />0 <br />2. Y.... R........l WA•.. e.w•d I.M 1 /.n.IH,.r� °n' F•e.e.wu eJ°'r Mwurun) <br />0. STATE e. CouXTY <br />NPRRAFKA <br />D. UTY. TOWN. OR LOCATION <br />r. LENGTH OF STAY IN Ie <br />r. CITY. TOWN. OR LOCATION <br />M "-A <br />ItyS <br />GRAND ISLAND <br />d. NAME O '// n0 rn AO•plfal, 9111 anal Oddrcan <br />d. STREET ADORES, <br />o <br />11"ITUT�o« �'1. • VOL posp <br />416 WEST AVE. <br />r. IS PLACE OF 0 ATH INSIDE CITY LIMITS! VISIT NO❑ 1 <br />r. IS RESIDENCE INSIDE CITY LIMITS+ YES J. TARN RESIOENCET YES <br />l NAAY oI k0.1 Middy L., <br />4. DATE MPnfA DOSE Y<nr <br />D[ciJ,s[o m WILLIAM <br />TYJN P. <br />DEE:TN S L 5 <br />5 SFY <br />tEA CE <br />7 ARpNO NEVER MARRIED❑ <br />0 0 E o' B�TH <br />9 AGE <br />e."AWIDOWED <br />FONDER 241RH. <br />�,T6 <br />❑ DIVORCED <br />— <br />^ O <br />I°el <br />On'orY door <br />IDe.N IND OF BUSINESS OR INOUSTRCI <br />I. TOPLACEISINr or Jorrrpn toun(rY1 <br />12. CITIDA OF WNAi COUNEM" <br />AL/ /WOR/F�RI <br />I SELF U <br />1 <br />IT.. FATHER S NAME <br />13 b. MOTHER'S MAIDEN NAME 14. <br />NA. OF NUSPA11prOP <br />KINGSLEY PHELPS <br />ELLEN JONES <br />� I[V�� <br />IS WAS DECEASED EVER IN U S. ARMED FORCES+ <br />16 SOCIAL SECURITY NO. <br />17 IN IORMANT Add—, <br />Wife Phelps,Grand Island,Nebr, <br />UNKNOWN <br />UNKNOWN <br />-Mable <br />IB CAUB[ OI CH ATM )Enlrr oMy ont roues fins /nr (o). (A), and (r).) INTERVAL <br />BETWEEN <br />ONSET AND DEATH <br />PART I. DEATH WAS CAUSE. BY <br />ESCNIA' 1: N �l % h 'Vi <br />�II3 �(/�; <br />M E 1) _ <br />MMEDIYTE CAUSE (A) _ (+� rY <br />N.i,, p fAU der. <br />DGE To <br />\ <br />PART II. OTHER SIGNIFICENT CONDITIONS COgIIIEUTING TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE CONDITION GIVER IX PMT'(.) IN, <br />WA`No0.MEEDD?' <br />YES HD ❑ <br />F <br />2DP ACCIDENT SUICIDE HOMICIDE <br />20e DESCNIBE HOW rNJURY OCCURRED. (5nlrr nWUrt o /injury in PR11 for Part 11 of Ord RE) <br />❑ ❑ ❑ <br />< <br />2Dt TIME OF hour MP11A, Day. Yro' <br />INJURY b. <br />D. d. <br />I <br />2ud INJURY OCCURRED <br />214. PLACE OF INJURY ([. p.. 1n or oArrW Aodt. <br />20/. CITY. TOWN. OR LOCATION COUNTY STATE <br />:MILE AT ❑ HOT WHILE ❑ <br />WORN AT WORN <br />lard, (o N", rtr«f, oJJitt ddp., rl[.) <br />_ c <br />21 1Bffendedthedec -dfrom ��EE- -_.ro = •nd 1Ae °Aw AJire on <br />D.eth occurred Bf __ A�[— __� m on the d. is efAfed Rbov And fo the be.r oI ml Anowlsdys. Isom the oeuw..fAted. <br />710 MATYBB[ (/MO'rt Or fl /!rl 776 ADDRESS <br />724. DATE SIGNED <br />19 uo� <br />yq. <br />27o BUR L. C0.LY 2:0 DATE NAME OF CEMETERY OR CREMATORY 3d. LOCATION (Ci(Y.lobrt. 0' only) M—) <br />R PCSCi� y' GRAND ISLAND NEBRASKA <br />9 9- - - -._ <br />.- - .';129L — <br />24. DATE RECD. BY REGISTRAR JX. REGISTRAR'S SIGNATURE 26. NAME OF MORTUARY ADDRESS <br />.BELL rN dneBA I�,!� n .11 LIVINGSTON& SONDERMANI`I,^GnND °ISLAND <br />:I <br />1 <br />4 <br />S(� <br />