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Al <br />() <br />PHS7931 V Ss REV. 7-53 STATE OF NEBRASKA { w "I <br />DEPARTMENT OF PUBLIC HEALTH, DEPARTMENT OF HEALTH `; N <br />EDUCATION AND WELFARE Bureau 01 Vital Stat6tioa <br />CERTIFICATE OF DEATH STATE FILE No.-..__ <br />BIRTH NO 128.. - -.. _ <br />___ ___.. -_ - reeldence <br />- - - - -- - ?. - USUAL RESIDENCE (Where db. COUNTY Itved. It {netltutlon: <br />1. PLACE OFDEATH a STATE b. COUNTY before admleelov). Ra <br />e. COUNTY Fall ) ._ 1' 1tdee <br />^ write RURAL) <br />b. CITY (If outside co porete limits, write Rural SLAY N G T H OF I., c. CITY (If outride corpo <br />rate Itm.ta, <br />OR &rid.151'.1C1 _J ^ : rl TOWN <br />TOWN ' OOCLR9� °1 <br />r - (I! rural, Rfve location) <br />d. FULL NA," E OF lif t to h Dl 1 or tvatitutio.. e.v t t d. STREET <br />Op add )' ADDRESS <br />y INSTITUTIO t r1L17C18 t.0S�1t, _ - - -- pa Year) <br />- -e. lF.re[) -- h. (M.ddle) c. lLertl 14. DATE (Month) ( y) ( ccoo <br />9. NAME OF DEATH 16 19 Uo <br />DECEASEU �t 7[; �7r <br />$ __.IT, r Print) ,. mjl-_.� — +i�._. .- __. _ - "'.�'il1S �'`�1 <br />5. SEX 8. COLOR or RACE 17. MARRIED, NEVER MARRIED, e. DATE OF BIRTH 9.leef bl tha r) IMcendor Dater If Houreor 2M n�a <br />WIDOWED, DIVORCED (Soecit)i <br />la _ Vl111t e CBgY'rl ed - — county) (State 12. CITIZEN OF WHAT <br />1!o tired) OR INDUSTRY PLACE for <br />rnuntrllb GAUNTRYt <br />loa. USUAL OCCUPATION (Give kind t klob. RIND OF BUSINESS IL BIRTH- lCity, to <br />ne durinR moat of wo,kln8 life, ev a Gr n o A. <br />ME`i13__ retired) llb.rNAME OF HUSBAND OR WIFE <br />V 13. FATHER'S NAME 14a. MOT TIER'S MAIDEN NAME r <br />iman Ki._ekhnsc lL �v„— d-- -°tH?i 1d4ydi%. <br />S'rl.n. - N0. <br />16. WAS DECEASED EVER IN U. S. ARMa tiles ORCESrTeJ 16.3 CIAL SECURITY 1P. INFO ANT'S NAME or mature k <br />or unknown Ilf y e've or eery <br />(Yee, no I ___ 506 -14- x;338__ <br />_ _ Iatenai Between <br />�— _ MEDICAL CERTIFICATION Dnwt th <br />DEATH. <br />a nce) 1 DISEASE OR CONDITION L / '/) DIRECTLY LEADING TO DEATH � „u(.. t me.n the ANTECEDENT CAUSES Y...'�L� �� ... . DUE To cb(L.. ech , uthenla„ Morbid condition-, 1t I ¢Ivfne <br />ate. it mean. the dir- rlre to the above eaoae (a) atatine <br />e.ae. Inlar >. or mmDllca- the anderirine cwre W4 DUE TO (c)_........_...._......._.._....._ ..............__............... <br />tlon which ousel death. <br />11 OTHER SIGNIFICANT Cha Did`Ih -1`0' rot <br />y c nasH man . <br />6 �. trr Isted to eluue dition <br />__ <br />e ICI 19e. ATE OF OPERA 196. MAJORFINDINGS OF OPERATION yea ❑ No �� <br />TION <br />El2 E PLACE OF INJURY (e. R.. in r about 2 Y OR —TOWN) RUB (COUNTY) (STATE) " 'I <br />lit 2[a. ACCIDENT (3perltY) Ih f m. ! t Y ­et. office bide•. (If rural area write <br />SUICIDE <br />21 INJURY OCCUR O zlf. HOW DID INJURY OCCUR? <br />C 21d. TIME (Month) (Day) (Year) (Ho ) I ylhi)„ t W k I <br />INJURY Not Wh 1 t W k <br />OF ro, —.. ' <br />/ L 19es Tto 19J.., that I last saw the de- <br />F22.7 herehy certify that I att°t3ded the dec llse6 from / <br />" _ceased alive ox .c:. /i', 10.}J .. --d that eath Burred at Jr the causes attd Ox the dat sDAted9 <br />w - f 23e ADDRESS )� - ..r /' <br />29a. SIGNATU1iT 1 L ('�'"� <br />k—, to .�yt' qp) (etatel <br />$ I n ME JF EMFTERY OR CRY i 24a. t. <br />21.. BVAIAL 24 DA' E eve. <br />CREMATION ❑ 17/19/58 �+estbt�wr ;.le'lrorial eland N <br />,e REMOVAL�/SDecifr� -. -- 25, FU RAL DIRE OR'S RE ADDIIE88 <br />wi <br />all pATE <br />JUL REGD�Y LOCAL I.ECISTR,;R SIGNAi`yTj� _ YYOOdRiVeT ATebT. <br />sued October 14, 1960 <br />0 <br />43� <br />