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11 <br />Issued February 15,196. <br />`77 <br />STATE OF NEBRASKA . <br />' DEPARTMENT OF HEALTH <br />Division of Vital <br />Statistt¢s <br />2827 <br />STANDARD CERTIFICATE <br />OF DEATH <br />DEPARTMENT OF COMMERCE - <br />;A <br />BUREAU OF THE CENSUS Sacld 9ecurit> No .................. <br />54[e Fit. No............... ............................... <br />o <br />- -- <br />1. PLACE OF DEATH: <br />(a) Co¢ot9... f- Lm1.....- _- _.._.._., _...._ ..............._ _._._......__......._._.....__- <br />2. USUAL RESIDENCE OF DECEASED: <br />in) s4tL� L1 ;.._2.a./%2r.... (1,) ca¢ntY_fd:.CL..L .......___........... <br />e <br />a <br />d.� ..........._..... I .............................. <br />(x) C119 ar 4wa..J.;l JI'i.r...�..:l.... <br />11t Dania. eit9 or todn rot., write RURAL) <br />�. ... <br />(r) city or town........% 2. 9_.: 1�... �. 1. t...:!':....._ ............... ............._................_ <br />Iimi4. write RURAL) <br />a(e) <br />N/a of hospital or Ined.d.n: , <br />L4 ?:T11.........1.21....�.�4.1_1 � /,°f.l_........_ <br />(If outside city or town <br />Street No......_........... .....................:..... <br />......., _f.�.:i1.�..:._�. <br />(It not in ho 11.1 or 4stitutlov, wri4 area[ vdm�cr or loatiuv) <br />(d) ._....... _.._._....._._ ................. .. .... ..._ <br />_ (If rural elvc location) <br />(d) Length of sW: In hoeDttel or Imtitutiov.__......_.. ...._..._..._.......... .... <br />, <br />. <br />o _..]coca. <br />() If forelgv born, how lone to U. S. A.? ........ ......_......................,. <br />� <br />in 'hie communit h [her yre., boon.. or 8.I.......... .... <br />MEDIICC�A�L� C�ER�TIFICATION <br />20. Date of death: ........ .mdmanta_f!�l,O/./...._le. <br />p[J %�� <br />1W FULL <br />.T.�.... . <br />._...... <br />....._.......____._...._. hem�......_..._.Y._.�.. <br />Dlb) If va4nn. <br />2I <br />�Ia �he�re�hY� oert11. �t-h^at I attended tho dace " from_.. <br />...L4A.+.._l%/.V....... 1D.. ...:F._t?.......- r- ....{.. _. 18...J. <br />camewor......._._....... .... _ ......... _ ............._......_.......... <br />or <br />.........._........__...._..._. <br />e(a) vela, wldowod, mersled, <br />Oat I Imt mw h.LliL.eltve on ..... ........._..a.. _............_..., <br />pp' <br />1I8. /CAo/lor <br />�% �. I <br />, <br />Duration <br />nod that death occurred on the dodo and hour e4 above. Durauon <br />EE <br />8. Sex___.. -- aae- ° - -. - -. <br />aworsd....r.Y1.�.L..._ <br />I 4 of aeatb__......_.._--- - ............................ <br />GOT)) Nt� of w 8(c) Age of hmbavd��orpp <br />... _. ..._........ _. <br />4hnebaad /.or /ife <br />_.S4..J1..11.L.1.... LQ_',• d1e If &H.._av_g...9re. <br />'..L.......1 ;F <br />... ..... _ ... ...- ...._ .. ...... ...... .. <br />7. Blrth da4 of deceased.Q ..11.. ..._./.8..8.8_....... <br />(Month) (Da9) (Year) _ <br />.._ .. ... .._ ....... .... <br />....... ........... <br />8. ACE[ Yenta Montba Da9e <br />It Ices then ono da> <br />.._.—....__..__....._. .._- ........................... ,,,,,,,. <br />a <br />S <br />_ _ <br />I <br />p..__._..__....__.._.. <br />O <br />..min. <br />._..._ ._.......__hr....._............ <br />...._'__"_--__........__............---..._............_ .......................... ............................... <br />Other <br />5 <br />o <br />madlHona__...._......___.__....__....._ ...._....._ ..................._ <br />(Inci¢de Dreavanc> wlth4 8 months of death) HYSICIAN <br />P <br />(City. town or U) (944 or foroiea eouvtry) <br />to. Usual ooevDauon... yrz.. 6.4..,$..C..La�.l.,�..C........ _........._ .................... <br />............... _ .................._....._.................... .._...................._....... _ <br />Ma)or [iodine.: Uvdorlirw <br />4 <br />q <br />it. Industry or b..u/alceae............. <br />12. Name....1f P�I.IL... . 6.l.S.G.: /..._ ................. <br />Of operation a .......... .................._._.......... _._.. _.... _.................. <br />.. ..........._......................_...._.__............_.......... .........- ..................... <br />the h T <br />eh o¢Id b. <br />1& BlrthvI...._....._.. .. AI�S.i.J.J..�....c!.Y....t.... <br />0. (CItY 4 ¢ t) (S44. f 1 ....) <br />Of notoinr ..._........._..._._........._._ ..... ........_............_......... <br />....... ....... .......... .. .. ....... ..... <br />[let i 11 <br />en Y. <br />nn <br />` I1. Maid.¢ name(h _t t). � � <br />due ceuaee, till in the following: <br />— <br />$ <br />«0 18. Birthi0non.._ :................. ... ....__.. t. .. <br />u .....f > <br />22 If death were 4 ex4rnnl <br />9 <br />i3 (Cit9� M.wr., o: U+uuty. f3 n or forcitm vtn) <br />(a) Accident, suicide, or homicide ( scecifYY ...................... ............................... <br />(b) Da4 of oecurtence.... ...._ .... ......... ............................ .... _........... <br />w <br />lh) Add��roet ......o .. i .... 1.7 <br />1T. la)...{._.+.'. ^!... ........ b) D 4 t mf..'f. ?Q. /..Y.Y.L <br />(Year) <br />.. ......_ .. <br />(e) Where did I.j., occor?....._ . ........ ......_. .... ...... .... ... .. <br />lCit> or Own) (ConntY) (344) <br />In home, on term, 10 4dueMel in <br />(Dur ol, �atlot. <br />(e) Pln bun.l er 0 JI '.. ='.Y !._: /rr9._ <br />�1. -" 'l <br />(d) Did lnivey oec¢r or about place, <br />public P11my ...... ...... ...... .............. ..... <br />9(<It <br />ce of Divee) <br />9 <br />18. (a) S: .f tan I dlrecbr)� /- - <br />While at works ne of I'Jun.......__.........__.._. <br />(M <br />y.., y� <br />18. la)....D +- �� /IJ:riC/lL. <br />( " "" <br />28. 91¢nat .. ... ... r).. .. <br />Addrae.... .... ................ Da4 rn¢d... <br />ed loco ei... <br />_(rieal.t nrtvrc) <br />.. <br />11 <br />Issued February 15,196. <br />`77 <br />