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N. <br />FIIS ,IR VS RFV 4-57 STATE OF NEBRASKA <br />a <br />DEPART \EFNT OF PI: 111,11 EEF:AI.TH. <br />EDUCATION AND ue1.FARe DEPARTMENT OF HEALTH <br />•, Bureau of Vital Statistics <br />BIRTH NO 126.. . -. CERTIFICATE OF DEATH STATE FILE NO <br />o <br />e✓"r..dwo.o,l I <br />ti II <br />1 I z <br />C <br />j. <br />1 <br />E <br />« <br />,E <br />{ i tv9 A <br />J x <br />!� r <br />[ N 2 Y [ID[NC. I APA...emd,• D C Rrd..w <br />`HD a`11AI OLNTY " Hall <br />Hall LVebraska <br />- <br />IA CITY, TOW1. <br />CITY In 111-170n LEnGTH OF STAY N r. OR LOCITIO1 <br />GT'allu lsl,nu Grand Islam <br />d H h no d ITIfET ADCHISS <br />Lutrler a hOS12itkal 2307 %e t rioeni St. <br />LIMITS TES$1 NO ❑ r I5 NESIDfnCE iN ITY L M TS YES J. EARN RESIDENCE' Y110 <br />NO ❑ <br />AN[ oY m- A DNY Year <br />3 /I.er \fidN. Laer d o <br />DlC[A[[D OE <br />COAT. Jul 1 1960 <br />` <br />rylRx.R.inl, GLLNti FobEb FRY <br />5 5FK <br />COLOR OR RIC[1 <br />T MARRIED ❑ NEVER MARPiED❑ <br />8 GATE OF BIRTH <br />9 AGE in yrnrA <br />IF UHM �MN <br />ItIt IA MRS. <br />M <br />j6 <br />,ale <br />VI'tkite <br />w1DOwLD® DIVORCED <br />2 -16 -1880 <br />fad ArfAdRY) <br />�G <br />Me,WR <br />Ween <br />IOa 1 LOCCUPATIOH !( %ur kind n(ROrk door <br />10) KinD OE BUSIHESSOR INDUSTRY II <br />BIRTHPLACE ItiINt or (PFrlpn rounnyl <br />12 CIiIHRR wxAT DOUxTRYf <br />a';ano mou R/ MP.kinp Ap. m<n i /.rmrdl <br />wire �h�el <br />Tele none Go. <br />Hancock Count Ill. <br />U. <br />13e. FATHER 5 NAME <br />111, MOTHER 5 MAIDEN NAME IA. <br />HAM[ OF NUSBAND OR WIFE <br />Loren T. FOSeber <br />&a ry L. Simmons <br />Stella Roseuerry aec. <br />IS WAS DLCEASED EVER Ix U 5 ARMED FORCES. 16 SOCIAL SECURITY NO. IT IMFDNINI A""" <br />" adM•,r .•I Mrs. lva Roseoerry, broken bow Nebr <br />IN DAU[[ OF MATN (En- ..IN ant raver Pa hot l ^r W. Im. and In 1 IOT[RVAL B D T" <br />PART 1 DE 15 CAUSED BT ON ET AND OfArM <br />IMMEDIATE CAUSE I.) __�� ✓✓C/(([( ._ <br />C.RdirR I /Rn Y. DUE TO (6) _ - -- <br />AIrA Oar. 'u,R�P <br />RI uF <br />fafin0 fuu H dtr- <br />TO <br />f <br />IYIRp r Fr /at ELI (r) - - — <br />WAS AUO Y <br />O <br />PART 11 OIAR 5 .NIFNNT Cp DIT C iK O MTH U <br />PRFORME01 <br />ESO No❑ <br />U20P <br />A H E <br />CIoHT SDIoI DMoD <br />2M DESCRIBE How ,nJUxv OCCURRED (t.'nrer nature o /Injury In PRrf 1 or PRrf II o /item 18.1 <br />? <br />�1 �nivR F. m. <br />Z <br />i0d INJURY OCCURRED <br />tar PLACE OF INJURY (r. 0 . In or aAOUI h—, <br />211/ CITY. TOWN. OR LOCAIN)M COUNTY STATE <br />wHLL[ AT NOT WHILE <br />wogK AT WORK <br />/arm. /erfory, At ...1. ,fC, Ndy., 11(.) <br />21 1 • t,nd.d fhs dsce.redyom _ 7 -- ( And lerf uw h °m .live on - <br />C fo the bert Of mr knowlad�e. /ram the uuYee efAFed. <br />fh. dAf feted ADove. And <br />DAArh occurred Af e e <br />221. DATE 51GNE''0// <br />I2[ [ID YW[ ((ROrrt or fUfe, 1 OAII1 <br />2b DATE 23r NA OF CEME ERY OR CREMATORY 23d LDCATION I('if ,town. Pr rounlyl (SYNC) <br />2b B I ERf YAT1ON. <br />RE.DY,I LH rvYl Gr_rw lsland, Nebr. <br />burial 7 -16 -60 Gra_islann�___ — <br />2A. DATE RICO BY NEC ST AA 125. REGI-TBAR 5 SIGNATURES // 2A. NAME OF MORTUARY ADDRESS <br />Bn 22 1960 i (- /1 ;N Livinr.ston- Souaerwarur Grana Islam <br />a <br />v <br />r/ <br />