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September 21, 1960 <br />30/ <br />a <br />t <br />v <br />I <br />1 <br />i� <br />�r <br />P <br />NEBRASKA (STATE) DEPARTTdISINT OF HEALTB <br />Divielom of Vltal StatietIm <br />'\ <br />STANDARD CERTIFICATE OF DEATH j ( X759 <br />W: UEY:IATMENT OF CO,f%ERCE <br />j:�.l dlittE �.0 OF TtIE CEV SUS <br />.... ......... No. <br />. <br />i. PLACE OF PE. tT II' <br />.......... - State File <br />(n) comfy..___` --- 811...._..._...._. <br />2. II9UAL RE33llENCE OF DECEA3ID: <br />- <br />... ...._........._......_......_.. <br />of (b) City or [own...__L?.Qn han_.RurH1....._ <br />ate Qk <br />s ._.___.... -- <br />() 9 the r.. _ (b) <br />-. . <br />zd of a-U a clay nr wwa umd,. wriw �...._ <br />(c) \ame of hoeDitxl or Inrtitutlm: <br />(e> City or wwn._._DOni�han_..RuTal <br />�. <br />1 mi South <br />�_....._.. <br />(If outelde eitY or town Illm -ite. write RURAL) <br />........ .......__......._..... _.. r ....__..._............_....._.. ..................... <br />3j l]! not in boaDltal or Inaitottm:. write street aum�ber or location) � <br />1 m1 South <br />(d) Street No._. ...._.....______...._- _.._... -. <br />i <br />Gil rcnatb o! etaY: Ia hosDi tai or Inaitutlon .......... ....__. <br />•. (If rural ¢Iw Iooatlon) <br />In this comet ft -1 r <br />nn y..._._.... <br />fe) ti to _ <br />reiw born, how Ion) In U. S. A.t..._�.T..s� _. -.._ .___'��. <br />�. <br />whethery ............ .............................._ <br />(Scecltr r days) <br />MEDICAL CERTIFICATION <br />;tm Tucker <br />afs) FULL NAME..._Fr$nC 1e......._..._ <br />20. Datetnf death: <br />................ .._..........._......._........ <br />A(b) If .refer.., - <br />_ _ _ }� <br />....here.._..cert...y that 1 attended the decueed from_._ea,��,•„�j . <br />21. I hereby <br />�..:M <br />nueo war._. <br />biYb 3 <br />ale <br />ate <br />a(aj & nale. widowed, mar. <br />than last eaw h _..Wive on -... iln�_ 6w 119 <br />1 <br />.. Sc :...._........_.._ <br />O)dried dl- <br />and that death occurred on the data and hour atated .hove• <br />Dontlon <br />I� <br />I 6(b) No- of husband <br />race..._ .............._ <br />or wife <br />ceed....._.... ........... _. <br />6(e) A- of hneband or <br />Immedlate cams of daeN._--_._-__._._. .......__..._.._..._...____.... <br />nnT, <br />CAE A.( <br />C <br />Esther h <br />wife If ellre....._...Jra.�ry <br />paT my nl .r <br />3z_ �.._..._......_...._...._._.. <br />l <br />r•_".;__ <br />7__ Irth___._....f dec_..I1.�.Q.1!i...... <br />7. Birth oats of dece,ued.:._!� aYl....._ ................. ... .l <br />. <br />Doeto._.........__........................................... <br />(Month) file)) (Y ) <br />......................_.. -..... <br />...._.._...__.._._ <br />iS. <br />AGE: Yeah Month. Uaya It I- than me dnl <br />'.__.._..___.._......_.._.__......_ _.......__.__....__.....__..._- <br />_ --------- _._. <br />° <br />67 <br />4 <br />-_._--_.._.._......_ ........................ _._ .... _................... <br />__— ..... .._._ <br />s" <br />i o.R,rwDl.re_Oxfordehire. <br />1�- <br />other cnnaluen. ......................_...................... ..............................' <br />I <br />c <br />- -' -- ._--.._ <br />- tatenr fore) <br />(City, t n, or county) (state or torelan oogntq) <br />30. Ueval occ uDation_± 3ar� '.Q'_....- _..._.__.._..- - - - -- <br />I 11. Indn.t y n - <br />°? , --m <br />(Indnde are¢eanq withive monthe'o :duth)' <br />._..--- <br />PHYSICIAN <br />- . <br />o ;lam <br />D1�lor Cndior.--"-. •._._._____._.._.. -____- <br />Dt aDeratima- <br />a <br />6 3Y. Name._ ........ ......___..._...._d.1b.Q�Q.r... <br />- -..._ ____.._.._...._..._..__ __ <br />-.._.- _.__ _.._ ... ...... - ___...__- __._.._- <br />Of aaeov .y.- •--- ..-- .- '-- -- --...� <br />the° <br />Rhfeh death <br />eb..Id a te <br />o, (City. avn, or m ) (Stet. or torelan country) r a hens <br />u. Malatn name ....................Y_........ _. P_._ ._........QX!.- '-„--�- <br />-___ <br />_........._ <br />0 16. Rirthn lace_ ...._.__..- ..._ ............._._ __..T�t ,y., R. _. _.. <br />�2i�.dt. AJfi. . <br />2 . It death was due to azternW eaaeee, NI I. the Io11ow1nai <br />..:; <br />_ <br />< (City. town. or cowl) 8 to r rel <br />fi• ��$$ (pp jp 8y� <br />'r-try) <br />18. (n) Iuformant'e (71[er <br />own .mat <br />a) Aside <br />( nt. m1oWe. or homleMa <br />w <br />are..__.`._._...._. <br />"' -" - -'_ <br />(b) AdQreaa ._..._.__.....__.- ........--- Qn. h ._.... _._..i _ <br />a 23L1 _ mod <br />17. )___.._._r_ka�...___....._ (b) Date the reof.......�._._T.._..._...._.._ <br />(b) Data of oecarnnea <br />(o) Vn.. dId ivfoq oeemt__..._.._._._._... ....._(('mnb) <br />g <br />i <br />Hur[W, cremation, or remove0 n ay) <br />» (Mont���...... ( (Year) <br />Place; <br />(fritl or town) (R, <br />(d) Did In1vq .sear In ae about home. w farm. In IadoatrlW plane, In <br />9 <br />burial or .rem n `f_.._._... <br />Is. (a) 311netare of funera <br />i <br />(b) Adyl refflva�....._....._............ _...........Y__ ✓..- "_'._t/.•.. <br />J <br />(Unto recelet�9a aTrF "��.r� (R�a ••: u'. elFnatn:.) <br />Y.. <br />Addren.._:......A�. <br />nD. <br />.11.QcSAA1 Dated w- ,6�,F/.5- <br />September 21, 1960 <br />30/ <br />a <br />t <br />v <br />I <br />1 <br />i� <br />�r <br />P <br />