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.57s <br />PHS- 798(VS) REV, 1 -57 STATE OF NEBRASKA i�Ci:03;p�;yr <br />DEPARTMENT OF PUBLIC HEALTH, DEPARTMENT OF HEALTH <br />AND WELFARE <br />EDUCATION <br />Bu3rosu of Vital Statistics Apf er -C Funeral Hon <br />BIRTH No. 126-- CERTIFICATE <br />OF DEATH T •• <br />- - - - -. <br />,tf ..................... <br />2. USUAL <br />I. PLACE OF DEATH <br />EBDENCE(pha lau.d liw/. 1 /i�wlihdw: Rridwwr Win .d.iNin) <br />i <br />a. COUNTY <br />Hall <br />a. STATE 0. COUNTY <br />Nebr Hall <br />�p <br />D. CITY, TOWN. OR LOCATION <br />C. LENGTH OF STAY IN 16 <br />C. CITY, TOWN, OR LOCATION <br />' <br />Grand Island <br />17 vrs <br />Grand Island Nebr. <br />m <br />d. NAME OF (If not in hospital, give street address) <br />HOSPITAL OR <br />d. STREET ADDRESS <br />e <br />Z,,, A <br />z <br />INSTITUTION <br />St. Francis Hos,ital 1 <br />315 E. 6th <br />.,b <br />c <br />r. <br />e. IS PLACE OF DEATH INSIDE CITY LIMITS? YES ADO❑ <br />e. IS RESIDENCE INSIDE CITY LIMITS? YES <br />J. FARM RESIDENCE? YES <br />E-1.2 <br />u <br />NO ❑ <br />N <br />rr yr <br />3. NAME Or Fvat Middle Last <br />DECEASED <br />A. DATE Month Day Year <br />Q Ca <br />(Type or print) a <br />• Irwin <br />OF <br />DEATH -30 -60 <br />a <br />5. SEX <br />6. COLOR OR RACE <br />lmv(' <br />7, MARRIED Cy. *EVER MARRIED ❑ <br />8. DATE OF BIRTH <br />9. AGE (!n gear) <br />IF UNDER 1 YEAR <br />F UNDER 2e HRS. <br />Z-0 r7 <br />0 <br />I. <br />r`� <br />��a <br />WIDOWED ❑ DIVORCED <br />7-1 -1 <br />last bi"Aday) <br />1 rs <br />xsww <br />D.w <br />Hern At:•. <br />MA i 4 <br />W <br />100. USUAL OCCUPATION (Give kind of work done <br />du•ing most of working life, earn if retired) <br />10b. KIND OF BUSINESS OR INDUSTRY <br />11. BIRTHPLACE (Slate or foreign country) <br />12. CITIZEN OF WW1T OOUNTRYI <br />py I: <br />W ^ „rAN <br />0 <br />138. FATHER'S NAME <br />General <br />_Weeping Water Nebr. <br />USA` <br />(.y- � y <br />7 <br />13b. MOTHER'S MAIDEN NAME 11. <br />NAME OF HUSBAND OR WIFE <br />� $d <br />°ilton Irwin <br />? inerva Dowler <br />Mrs. ^`abel Irwin <br />�Ri <br />15. WAS DECEASED EVER IN U. S. ARMED FORCES? <br />16. SOCIAL SECURITY NO. <br />17. INFORMANT <br />Address <br />�O <br />sB�G <br />S.A.. ) <br />u,,Tdb° - f'174`!! '19 <br />(/ <br />507 -07 -49 <br />xs. abet Irwin, Grand Island, Tebr. <br />` '•` <br />xb .5md <br />, <br />18. CAUSE OF DEATH (Enter only one cause per line for (s), (b), and (c).] <br />INTERVAL BETWEEN <br />,[ N <br />PART 1. DEATH WAS CAUSED BY: <br />IMMEDIATE CAUSE (e) Acute avo cardial infarct <br />ONSET AND DEATH <br />G <br />Jc�xq. <br />W Y OEM <br />O al'2 <br />H <br />Conditions, if any. <br />to <br />DUE TO (b) <br />. yp'o <br />kl c <br />wkich gave risq <br />(a), <br />m <br />Q C U V <br />> <br />abose cause <br />stating the under- <br />lying cause last. <br />DUE TO (C) <br />W . W A <br />O6< p <br />= <br />O <br />1.- <br />PART II. OTHER SIGNIFICANT CONDITIONS CONn"BUTING To DEATH BUT NOT RELATED TO THE TERMINAL DISEASE CONDITION GIVEN IN PART 1(4) <br />. WAS AUTOPSY <br />All E W « <br />PERFORMED? <br />YES No <br />C <br />20a. ACCIDENT SUICIDE HOMICIDE <br />20b. DESCRIBE NOW INJURY OCCURRED. (Enter nature of injury ilk Part I or Part 11 of item 18.) <br />>W A <br />U <br />11 ❑ ❑ <br />,Z <br />V <br />20e. TIME OF Hour Month, Day, Year <br />INJURY <br />�uC <br />a. m. <br />W <br />p.m. <br />N <br />20d. INJURY OCCURRED <br />20r. PLACE OF INJURY (e. g., in or d*W home, <br />bldg., <br />20f. CITY, TOWN. OR LOCATION COUNTY STATE <br />I•, <br />WHILE AT ❑ NOT WHILE ❑ <br />WORK AT <br />farm, factor/, stred, office de.) <br />WORK <br />E D <br />21. 1 attended the deceased from , to and last saw her alive on <br />O, o w <br />Death occurred at m on the date stated above; and to the beat o/ m� knowledge, from the causes stated. <br />w C u <br />22a. SIONATUM (Degree or tOk) <br />22b. ADDRESS <br />M. DATE SIGNED <br />yv <br />C. H. '•'aggiore, MIX. <br />Grand Island, N ebr. <br />E. `a v <br />E. m X <br />23a. BURIAL. CREMATION. <br />REMOVAL (Sptctfy) <br />23b. DATE <br />23r. NAME OF CEMETERY OR CREMATORY <br />23d. LOCATION (City, town. or County) (Slate) <br />(o '" <br />- <br />I`lest Lawn `,, emorial Park <br />neter Grand Island T1ebr. <br />'Z, N <br />N. DATE RECD. BY REGISTRAR <br />25. REGISTRAR'S SIGNATURE <br />26. NAME OF MORTUARY DD SS <br />dome <br />Apfel- Butler - Geddes Funera� <br />Grand Island, Nebr. <br />.57s <br />