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I <br />r, <br />DEPARTMENT OF HEALTH ��,' A 1794 <br />} Division of Vital Statistics <br />l3- <br />DEPARTMENT OF COM\IERCH <br />a..... If the C.a,a, STANDARD CERTIFICATE OF DEATH stew PD. <br />STATE OF NEBRASKA <br />t J <br />I. PLACF. OF DFATR: 2. USUAL RESIDENCE OF DECEASED: <br />(e) County ms's ~ <br />I � stave - -- - -`GLa - -- Island. ° "Hall - - - -- <br />', a m ov ° t Lin"', -- -- -- – r nd --- -oaaii <br />(If o sid° city o [own limits. write RURAL) fc) City or town -_ _ __ —_- -- - -- - <br />�. i R <br />o, (c) Name of bospitnl or Institution: (If outside city or love¢ limits, wriw <br />�I– ylacnl - __er1__�sn – -- -- - - - – -- `?ll_i'est_oth. -,9 - - -� <br />(If t t h u t 1 or vest tution write nroot bcr tl J (d) Stroot N <br />i eI (d) I ¢th t t y In hoe Ital or institution _ o location) <br />or ore <br />q,d+s so «Irr we =7 ' ' j U [t e <br />(o) If f h rn. fiow lov¢ is U. S A.? -- - -�' <br />f hi mu h dars) <br />fill_ — — .— — <br />1 �, •r y�� , ,,Y MCDIC.AL CERTIFICATION <br />1 0(a7 NULL NAMFI`�12.WAa u_'.1..L1- __.a- ayl'J�_ _ BC. <br />xo. Dnw et death: <br />3(bl If veteran. . -- - -- <br />name 2i. I her�br]ytifrJ.[Ihat I tIo.d.d tho d.—d from=--- - <br />6. Color ° _ 16(a) Sin¢le. widowed, roar. -- "-`- ' -+r" 14e tO - -�=- ]9 <br />n Jj that 1 last caw b, —.lore oD- - - -L7�= -Z-- - -- - -• laid! <br />i.d. d .e.�rr e n <br />a 6 b) Name of husb d wife_ -_ - - -- 8 e) A¢e of husband or and that death oc rred on the date and boor A—d above. Duration <br />a ( av (M1I —I[ leas than o Im diate cpuee 0/ doat _ _ _ -- <br />or (wileY�f -a_ —_ I D <br />ul�wrc+ff� -_ -__� <br />' 0. Birth dato of deceasM_- tLrzit Day)_3 _ <br />on[h) (Day) _ (Year) <br />—_ I to <br />a y B. AGE: Yenn MOatbs Days a9 <br />j 3 0 — - - -- - -- w <br />Duo - - - -- -- --------- - - - -- <br />_ <br />- 9. Blrtholaeo - $1- p{.;,BL' r - --- countr>) Othor <Ondi tl -nu - - -- - - -- - -- — <br />.B co or lOrc�¢n ___________ -m <br />(City. town. tasty ute (Inrludo pre.,nuncr within 3 onths of death) PHYSICIAN <br />�. 10. Usual Deco Dati°v n" " ''1 rC-Q a --- - -- — Uvderlin. <br />11. Industry or huainess - - - - -- --- ______- ______= __ -___ '.. _a or -f nDdines_ -___ the cause to '.. <br />whleh death <br />-- should b s j <br />wl City.6dAf.- ht'eoaT[Y)(S[ate Or <br />fore eouptry)� Of IInt° DS9 _----------------------- cher¢ed stw <br />----- _ tietically. <br />1 a"aea — -- =`- - -- <br />16. HmthD).. __ll,"�':i1C1 ='31 <br />8� (City, wwn. or w t ) 15t tt�: r rti¢yM u try) 72. If death was due to °oroini l c A'1 in the followi <br />t6 la) Informant's wp lenat�r.� ',i{ - y_21 to) Accident. c trrienea°r homicide - - -- - - -� -- <br />1 ° lar 1"( _1 y _�_� - -- (b) Date of o eu <br />(b) Address <br />j J 17 g ------- !L1 .r t? , fMeGiLyay)1 le)Wher. lid ini"ry c–T– –cc trort°�i 1c.nntY) -- (sot.) <br />Did njor, —or In or about home .n farm. , maastrial Dl . 1. <br />r `un rsa Ho. e D"hue p,aut _ - <br />`� <br />16 (e) s =n, to-e j O,l dirrotor (SDeci[y tr D. of pl ) <br />{ n (hJ .411 sit %;__ T 91 illtl 1 Whilo at w t1.y _ _ -- (e) Means of injury - - _ - -_ <br />a h. F it Si¢nat ''�`_ - --e�/ - (M- . <br />- 19 ( °i.. �.F �ocal re¢ atrarl (h1 Iha,'a -_ i¢natura) "o Ad..ress - •r( --- Date dined <br />t <br />V` <br />4 <br />2 <br />1' <br />tyt�* y <br />4 <br />