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t <br />a, <br />` ` ps1�i'p�� Ofd/ it )lll�rr (��(���((33 <br />too: e -S1 lohrlfiDft tNt \►flMiM '� STi7C)C)2 1 <br />CERTIFICATE OF, DEATH <br />FHOWiTAL ►eE fMl DtATM i. "OPAL iwrm DE (wh .d...r M... t /;,.eieM,w.: MiMtN.r r../winiw) <br />.. ,. ODURTT • " a.. STATE . e. COUNTY <br />W, ^ <br />- , CITY. TO1DN. 00 LOCATION r. LEIIDTN OF STAY M 1b C. CITY. TOWN. 00 LOCATN111 .� Islam <br />�t 2 wks <br />NAME OF (ry aw in hMPitat. FIPt Street, tlddro") OR j 11 <br />NISTITUTKIN <br />If OEATN IMS10E l M T[f NO t. IS 1 C L EARN RESIDENCE? .TES <br />,.. N0. NO EE <br />S: maxw M Jllrst A N& LOW 4. DATE - A6NA" DIED Year <br />09CRAGGO or <br />(Skr or Pd) AM4 M B ja DEATH <br />[Pgkbr 117 An <br />" .. SEX �� A COLOR .011 RACE . 7 MANOR NEVER MARRIED . DATE Of M f. AiE (IN MaP vM 1 <br />male CjY Jolt eirt"ev) r..r. Dye liver. Ate.. <br />WIDOWED DIVORCED <br />Mo. USUAL OCCUPATION (Gilt kiNd of work done W. KOO OF DUSNIESS OR NIDUSTRY 11. MRTI1KACt ( ok M JMeyn em") 1 CITMNN a< MINT COIMMRT? <br />dr•MF Mad NWOkiq hit, own If retired) I bhtrsw Ob)r U� <br />S• C Co <br />130. FATMEN'S NAME IIV.MOTNER'S MAIDEN NAME N. �Amee OF NUUAND OR WIFE : <br />Tire. J �/ J <br />.: WAS DECEASED EVEN NI U. S. ARMED FORCES? Is. SOCIAL SECUW" No. 17. owesomm <br />I r....... V....) w We, w..... 4". of w i l G1 vv /S ' J-Z J�O J Z � 4M1ilt <br />0 <br />FAME M MATH JSWN am OMM, M Mae yb (o). (e). (r)•I ?MOW A t OUT1N <br />►ART I. OEATN WAS CAUSED BY: <br />tMEEET AM OLATN <br />IMMEDIATE CAM (a) Carcinometosin <br />Carcinomatosisof`brain� bone marrow VITA <br />��itiMM.:' /oNr. DUE To (e) . <br />� team y%.- Primary site unknoxn <br />e +11 U* rN/er DUE TO (d <br />MM rArar fat. <br />►ANT 11. On= SMMn AAW CWMR10IS C7I "nUrIM TO OEATN So Me IMMAYN TO TMI TLVWft GIMME OMRNTI N SItEN M PMT I(a) W, WAS AUTOPSY <br />PERMOMED? <br />.. TES NO <br />mo: ACCIWNT SUMIpE NOMICIM 20b. DES"= NOW WJURY OCCUNWO. (JDAk► setw P/Mhrr in Part for Part !! sf ilew 18.) <br />❑ ❑ ❑ <br />fat TOOL OF Herr MM A. DO, Yea <br />ad, NIIURY OCCURRED mr. PLACE OF MIJUNV (t. ►�,.L{ i�N r AIoNt Asst. Nt. Cm. TOWN. ON LOCATION COUNTY STATE <br />VW" AT. ❑ NOT W/IILt ❑. 1p *, IAdorF. M/gt.,Flwr V*.. Mt.) <br />RroRK AT woRx <br />ii 7 attenMrt tar Mowlr 2 C . h 2— and /wt rw him <br />hor NAi►A on — <br />DaatA eoourtod at 1,U = jJ w Nw tan dote dNNI dM�r Atd tar tho 6"t o/ my::AwwJdM. from tar eAUw stated. <br />no. 904M*T%VA . MINIM or Oft) ii. ADOIIBS Xk..DATE SIGNED <br />John D. Hartigan, M.D. 527 Medical Arta Bldg. 2 -23-60 <br />Do. MArAL. t]w"Tok E*.. DATE Zk. (NAME OF CEMETERY OR CREMATORY !>il. LOCATION (My, MWa. or em") (ask) <br />X DATE RECD. Dr KGOTRAN PL A[GWItAR'S3MMTURE JA MANE OF ISO OMM A(IOREff <br />FE B- � w60 ' G -.� - .�/ 1 �e s"t o► a Haft "a rimam ors <br />0 I hereby certify that the above is a true <br />'i A L •, » ', and correct copy of the certificate of death <br />r .i recorded in,the City of Omaha, County of <br />Douglas, State of Nebraska. <br />r o G <br />r! �'. ' •I a T } tip' Dated this --/ - - -day of <br />egi sorter <br />