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+i 1 � <br />WHEN THIS COPY CARRIES THE RAISID SEAL OF THE NEBRASKA STATE <br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COPY <br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT OF HEALTH <br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY FOR <br />VITAL RECORDS �� 2 012 0 8 5 9 3 <br />DATE OF ISSUANCE ,� <br />���a� <br />��� � � STANLEY S. COOPER, DIRECTOR <br />LINCOLN, NEBRASKA BUREAU OF VITAL STATISTICS <br />STATE OF NEBRASK/1— DEPARTMENT OF HEALTH 9 3.,.. 0 0 2 8 6 <br />• BUREAU OF YITAL STATISTICS - <br />CERTIFlCATE OF DEATH ? - � <br />7. DECEDENT - NA6fE ' FIRST bUDDLE LAST 2 SOf � 3. DATE OP DEATH (MOnth Dsy, Yem) <br />James $i�hard Adamson J n 21 1 3 <br />a. cm avo srnre oF �arr� m�or � u.s.a.. �mna o�wyJ sa. Ac� - t.a� ew�day s. oare oF s�arM /aaae�a,. var. ree.l <br />rB.l sn. ►ws. � onrs sc. Hou�4 wNs <br />Albion, Nebraska 64 ; ; Dec. 21, 1928 <br />z socaa� s�cuanr rw►asex Ba PtACE OF QEATM <br />rrosvrrn�: � �,anen� o �w�a O ooa <br />507 � O� ❑ r� �e ❑ a� ❑� rsa�eu,•� <br />80. FACIUiIf - Name (Btqt 6�. 8hre s6pet artd �rj Bc. GiY. T�AJ OA IOCATION OF DEATH 84 INSIDE CRY UhtlT3 Ba. COUNTY OF DEATH <br />ISV�N Yes m IYOI <br />Clarkson Hos ital Omaha Yes Douglas <br />Ba RESIDENCE.STATE N. CWNTY <br />��� <br />Patho <br />ATMER . N <br />P� I <br />ia ACqOENT. SUtqD <br />OR PENOIN� 141VE <br />ie. pJJURY AT WpFOC <br />(SpBelly Y89 C►NO/ <br />9c CIiY. TOWN OR LOCATION 8d. S7AEET AND NUAABER (lndud6�gaP Co�eJ 8e. WSIDE G7Y LIWTS <br />/SpeCy Yes m No) <br />ka Hall - Grand Island 2121 W La�[ar Yes <br />�. �ck � u�man. ,,. ,wc�sran Ie.a.�,,. ►+e,�an. o�an. e�.l ,z ��v�p rv�EO. ,a wv� oF srau� /e »�ae, a�a mmaen r�rre� <br />lsre�h/ wroCweo. otvoac�o ISae�YJ <br />American 6 Married Donna J. Crabb <br />�arwN �m.e im�a a rax emre d,m� �r iae. �mo oF euswESS wa�srHr ' <br />'� �mmaay a seemwa�y (o-t2� i co�e �t-s m 5+1 <br />lo ist og3 Patholo Hos ital g 3, ' S+ <br />� c�asr uamo� . usr ,�. won+En . ww� wu� m�r wco� usr <br />res. no. a aucl m r�. 9�'e.� ana aatea ot �� <br />Yes 7-26-48 To 7-3-' <br />�. �,�. �.�. �. �� <br />o�, <br />Burial Jan. 25 <br />. AER,- S16NATURE 8 LICENSE NO. � <br />�. <br />�� �� � <br />; �� . <br />� <br />��, <br />WE TO. AS � Of: , <br />(hl �rl?�fAd �� � <br />DUE TO.OR AS A CONSECU CL �: <br />tcl �JV K.7N��(,^ � <br />OTHfR SIO.WFIC/1NT COUNI7roN3 . Ca <br />a��Y <br />�� <br />rLACC� OF IWURY - At IwmB. tarm. streel. <br />anee a�,�e. eoe. /sP�yJ <br />� <br />� <br />� <br />. � . I bttarval betweE <br />� <br />� <br />1 <br />� 1 6itmval Eeltiflc <br />1 . <br />I <br />Ui IF FEMALE. WAS THERE A 24. AU70PSY 2S. WAS CASE HE <br />NANCY W THE PAST 3 MONTHS7 /SpeGy Yes a NoJ EXAh6NER OR <br />Yee ❑ No ❑ /��41 (Spac9Y Yas a <br />a �a 21 � � 93 $ <br />�� � 270. DATE SNiNED � Oay, Yr.J � 27a TIME OF 9EATH . � �� �_� 28c. PRONWNCED DEAD ' . <br />� (bto. Day, Yt/ 28d. PRONWNCED DEAO <br />Z h '• ` <br />�� 270. T� � . p�� �� y� ��q ��p � m e�� �, p� � p� ot aitam6�Non aiW/u 6weatigattm4 In my bqtdmi deeth oaurr� <br />a <br />a nre e m e. aate a�M W e e e ane oue w e�e e a u s e �s l e m t e d. <br />&m�► M.D. a�e�an„e <br />28a 01D TOBACCA USE CONTflIBUTE TO oenmr 3oa..wtis oa�aN oA nssue ooruTww �u c�usioe�oz aou. wns cavs� awwreo� <br />O YES O NO UNKNOWN O VES O O YES O NO <br />31. NAME AND ADOflESS OF CERTIF¢q (p►�Y Cpry. CORONEH'S PHYSICAN OR (bUNTY ATTORNEN� (Type or PiIrCJ . <br />Vincent E. Miscia M.D. 301 South Doctors Bldg. Omaha,.NE 68131 <br />�a ��T� 32b. DATE FII.ED BY RE6ISTRAR (MO. Dey, Yr.J <br />� �� � . M•�•H• <br />�'�$ � �93 <br />� ..'� i�;� <br />� <br />��,i� 7Ca� <br />� <br />