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DEPA R NTE REV 4-57 STATE OF -OF HEALTH _ <br />�.- EDUCATION D PUBLIC HEALTH, DEPARTMENT -OF HEALTH <br />EDUCATION AND WELFARE <br />� Bureau Or vlwl s3aE�t(LS Fi 0 114 5 91 <br />W BIRTH NO. 126 CERTIFICATE OF DEATH STATE FILE NO. .._ _. <br />It <br />0 <br />r Be•rH <br />• uALLT . 7 <br />z uw•L N4.roRHU Iw.......- . «I.-e x..,...- en... +�..« -1 <br />•";WA SKA �D,��T ^ <br />h. C Tr. TOWN, O. ­AT ION <br /><. L[NOTN OE $TAY UI 11 <br />1. CITr TONH OR LOC +TqH <br />GRA *•D ISLAND <br />'BRAYD ISLA "•D <br />4. ­1 OF 11.M R ANIDd. FHr urrrr.ddran <br />d. ITHECT AODNESS <br />z <br />",1o„ 588 Blaine Addition <br />598 9laine Addition <br />.� <br />f. IS PLACE OF OCATH INSIDE CITY LIMITS' YE NO ❑ <br />r. IS RESIDENCE INSIDE CITY LIMITS. YES /. FARM RESIDENCE? YES <br />44 <br />• <br />t. <br />4 <br />a. DATE Me•YA D" Y_ <br />cLa <br />~:I°o`m +qn ESTH SLIZAP�TT? TUCKER <br />OE T. April 3,1960 <br />6 COL_ ON RACf <br />It <br />0 <br />"I <br />■ <br />4 <br />? / <br />r Be•rH <br />• uALLT . 7 <br />z uw•L N4.roRHU Iw.......- . «I.-e x..,...- en... +�..« -1 <br />•";WA SKA �D,��T ^ <br />h. C Tr. TOWN, O. ­AT ION <br /><. L[NOTN OE $TAY UI 11 <br />1. CITr TONH OR LOC +TqH <br />GRA *•D ISLAND <br />'BRAYD ISLA "•D <br />4. ­1 OF 11.M R ANIDd. FHr urrrr.ddran <br />d. ITHECT AODNESS <br />z <br />",1o„ 588 Blaine Addition <br />598 9laine Addition <br />.� <br />f. IS PLACE OF OCATH INSIDE CITY LIMITS' YE NO ❑ <br />r. IS RESIDENCE INSIDE CITY LIMITS. YES /. FARM RESIDENCE? YES <br />ND❑ NO <br />3 1MMt DI III,. ,E/lA41f LW <br />a. DATE Me•YA D" Y_ <br />cLa <br />~:I°o`m +qn ESTH SLIZAP�TT? TUCKER <br />OE T. April 3,1960 <br />6 COL_ ON RACf <br />7 MANRIED [[:TI ..A MARRIFO ❑ <br />S MTE OF e1RTM <br />9 AGE Ilq FtN1 <br />M oMOAm l Y[M <br />IMpERN N11[. <br />65�[M <br />C emale <br />Ci6UQa 918n <br />WIDOWED Li DIY_CED <br />O <br />^rarch 21, 1090 <br />!•1LONIAaeI1 <br />AY.,w D... <br />�• Yu. <br />101. USUAL OCCUPATION IDRM AI.A a /MNA AR.r <br />POD ­. Di eUSIMF55_IMWSTRY <br />11. eIRTHILACE ISrdr *1 1111" roN.h /7 <br />I2 OTIDI Of WW1T Od11111Y1 <br />4.•bF MW el NOrA4F hk. rx. i /Mirdl <br />Housewrle y, v^ <br />own home <br />Lucas Lucas o.Iowa <br />USA <br />13.. FATHER S NAME <br />116. MOTHER'S MAIDEN NAME 11. <br />NAME OF NUSBAND OR WIFE <br />John TJm. Shannon <br />Anna Ruth <br />Francis Wm.Tucker (dec) <br />IS WAS OECEAS[O [YEN HI U S. ARMED F_aS? <br />F » - -•w •---- �»� -^d' <br />—none <br />16 SOCIAL SEC_ITY Ho <br />17 IM A4r•N <br />?`rssth�r R�b�rsor�.8� Blaine Add <br />no <br />none <br />ran a n e r. <br />IB CAYet OF WfN1W IERm, RWI eu e..N Iff I—/. (.1, 111...4 (1)] <br />?ANTI MATNWASCAUSEDBY <br />IMTENYAL BETWEEN <br />SAND M6 <br />IRME -7 CAUSE I.) __ �l� -Gfia sir ��.•.�C_Il� <br />IRE TO (11 <br />MAwe <br />/H •I nwrR f� I DIX To R) _ <br />FRAY II Orin SM W ,e R CONMTMIM DONIRIMrt.i m a[AiH rUr Nm NOIIWD t0 <br />IT WAS A <br />IENFGIIMEDI <br />S <br />YES ❑ No <br />F 21M ACCO[NT U.I. NO... <br />OCNIL IgN UURY OCCUAMD /E+Ilrr gtlere s /Igj.rr i. POf I w PCl ll of Wrw li.l <br />y C ❑❑ ❑ <br />j IDf TIM[NM HNr Alwe, Mr. Y <br />LyS� wU r N i <br />Z 20r N1JURr OCNRR[0 <br />.+rl . <br />b/ CM. TOWN LOCATION CNIrtM STATE <br />WINLE AT <br />ROOR ❑ T NOIR <br />A ❑ <br />AN.". N"d. <br />21 I.ff.nd.dfM dAC...ed /rom- 1. ro �1W /ut MN h,a . /lr. oo <br />D..f6 oeeMrr.I.f 0I1 eM AIR c, s ".6 —...nd to eM ANNY .1 N kNoMAWte. from Eh. uMAAR *f.f.d. <br />�.. t1eYY111Wt (Dw.N llk) <br />tl6 ADDRESS p " lie. GTC D <br />2M MMML. co MAFO.. 211 GTE " 27r NAMMOFCEMCTERY_CREMAT_Y 234 LOCATION I(Yr, tAWN.N fe.MI) (3AEf) <br />Bu `a '"° 416160- rora Cemetery Aurora,Nebraska <br />—a -- <br />24. GTE aca w IIEGMRAR If. N[c:ali:ll ] :willf Yiln: ' y 016.Ibl�p , 1U �1 <br />p <br />�• I-l[it>, <br />AN 14 1969 Aur -ora, Nebr. 133 <br />7�1 <br />( r �✓i� <br />TRUE COPY 01, AN ORIGINA! <br />BUREAU • VITAL • • <br />FOR •• <br />i <br />-C;CR VITAL AND ASSISTANT STATE REGISTRAR <br />DI.R CF STA_:5TICS <br />LtNCOLN, saved September 21, 1960 <br />"I <br />■ <br />4 <br />? / <br />