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<br />PHS- 7ss(vS) REV. 4 -51 STATE OF NEBRASKA .
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<br />DEPARTMENT OF PUBLIC HEALTH, DEPARTMENT OF HEALTH is i.
<br />EDUCATION AND WELFARE 'Q� P`
<br />$U.reAU Vital A '
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<br />6D _ Oi Statistics fel— ULl — Home
<br />BIRTH I2 CERTIFICATE OF DEATH
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<br />. -. -; ....... STATE
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<br />1, PLACE OF DL_ ATN _ - - _ L USUAL REf1DENCE (WAas d.c ,W If i e��Rw,drnos 6s/ori adieiw_ion)
<br />a.. COUNTY a: STATE'
<br />Hall � .: Nebr v. all-
<br />b. CITY, TOWN. OR LOCATION_ -
<br />c. LENGTH OF STAY IN Ib e, CITY, TOWN, OR LOCATION
<br />Grand Island
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<br />34 Yrs Grand Island
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<br />- d. NAME OF 0frnot in hospital, pipe street address) - d, STREET ADDRESS
<br />HOSPITAL OR - -
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<br />INSTITUTION - - - -.
<br />V. A:. Hosr'ital - 134 Pletcher Terrace.'
<br />da ;.
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<br />_
<br />t, IS PLACE OF DEATH INSIDE CITY LIMITS}, YES ❑ NO O _ �' e. IS RESIDENCE INSIDE CITY LIMITS.? Q If, FARM RESIDENCE } YESO
<br />y
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<br />i - ❑�
<br />3. NAME of Firat= Middle Last
<br />- 4. DOTE Month Dny� YeaF
<br />DECEASED
<br />_ _. _
<br />(rv* or print) '' - °- - - -.
<br />Josenh L. EMY DEATH : -3 —b2
<br />SEX - -
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<br />C COLOR OR RACE : 7• MARRIED M NEVER MARRIED❑
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<br />9. DATE OF BIRTH . S. AGE (In yeah 1 IF UNDER 1 YEAR 1p,F UNDER N HAS. _
<br />last birthday) Moefkv De w How,, Mie.
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<br />M .
<br />W WIDOWED ❑ DIVORCED ol_
<br />' 3- 5 -18�� 73 yrs
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<br />w W do
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<br />IN. USUAL OCCUPATION (Give kind ofwork done lob. KIHDOF 13USINESSOR INDUSTRY
<br />du•iny most of workinp life, even if retired) I
<br />)I; e or / orei n BIRTHPLACE (Slat ) -,
<br />y country) ,
<br />_
<br />12. CITIZEN OF WHAT COUNTRY?
<br />°.',
<br />Ret, Elevator Operator U.S. Gov't I
<br />Illinois
<br />USA
<br />7 h"
<br />13a. FATHER S NAME - - 13b, MOTHER'S MAIDEN NAME,
<br />14, NAME OF HUSBAND OR WIFE
<br />v
<br />Charles Ern' Louise Warner
<br />-
<br />Yrs. AFnes' Erny
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<br />IS. WAS DECEASED EVER
<br />(Yrs. nn, or unknowel
<br />IN U. S. ARMED FORCES} la. SOCIAL SECURITY NO.
<br />(U y,,, six war w dal. of ...(.1 -_
<br />17. INFORMANT- - '- Address
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<br />vas
<br />T%11 T 505 1? -11971
<br />- - -
<br />M'rs.' Ames ErnY;' Grand Island, I'ebr'
<br />04 7
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<br />19, CAUSE OF DEATH jEn(er only one cause per line for (a), (b), and (c). ' - INTERVAL BETWEEN
<br />-
<br />,C
<br />e eW
<br />tt�,,
<br />PART L BYI
<br />DEATH WAS CAUSED - - p - - ONSET AND DEATH _
<br />IMMEDIATE CAUSE (a) - Congestive heart failure -
<br />roow�m
<br />- Q u A. o
<br />10
<br />Condittona,Many,.
<br />which Dove riaff to
<br />DUE TO (b) QYter•iOSC.lel"Ot?C rea.rt 01SeaSe
<br />lit y
<br />N
<br />O V b
<br />appoae Cause
<br />ataf� p tA.e undcrt'
<br />DUE TO - -
<br />W w x,52
<br />_ !yin cause las(.
<br />(t)
<br />. - ' O_t y -�
<br />Ada
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<br />O PART II, OTHER SIGNIFICANT CONDITIONS CONTNISUTING TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE CONDITION GIVEN IN PART I(a) 19. WAS AUTOPSY
<br />` - ` -
<br />- wY
<br />EA y
<br />• - - - - - PERFORMED}
<br />V -' YES ❑ NO Q -
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<br />¢ 20a. ACCIDENT SUICIDE HOMICIDE lob. DESCRIBE NOW INJURY OCCURRED. (Enter nature oJinjury in Pa(! 1 of Part 17 of Stem !eJ
<br />wo
<br />20e. TIME OF !four _ Month, Day, Year
<br />INJURY a, m.• - ', - '. -- -
<br />o P, m,
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<br />- w
<br />N
<br />W
<br />f 201. INJURY OCCURRED - !1
<br />WHILE AT ❑ NOT WHILE
<br />20t. PLACE OF INJURY (t. p., in or about home,
<br />form, factory, street, office, bldg„ etc.)
<br />120f. _CITY, TOWN, OR LOCATION - COUNTY - STATE
<br />- - -
<br />0Ci q -
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<br />WORK AT WORK I•
<br />111
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<br />21. 1 attended the deFtased from - to and lest saw him, aJiva on�
<br />_
<br />Death occprred at in on the date stated above; and to the beat of my knowledge, from the causes stated,
<br />22a. SIGNATURE - (Degree or title) -
<br />22b. ADDRESS- _
<br />22e, DATE SIGNED
<br />^s v
<br />Miles M INT. i Kelly, P .D.:
<br />� Grand Island, ?�ebr.
<br />23a. BURIAL, CREMATION,
<br />REMOVAL lSpec lJy)
<br />23b, DATE
<br />23t, NAME OF CEMETERY OR CREMATORY
<br />I
<br />23d, LOCATION (City, (own, or county) State) ..
<br />-
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<br />Burial'
<br />;-6-62
<br />Grand Island Cemetery
<br />I Grand -'sland, !"ebr.
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<br />DATE ATE RECD. BY REGISTRAR
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<br />- _
<br />SIGNATURE N
<br />2. REGISTRAR SIGA ".
<br />'S 5 _ - _ -
<br />26. NAME OF MORTUARY - - ADDRESS
<br />- -,
<br />Arfel- Butler- Ged:es,• Grand Island, Nebr.
<br />County cf A: all
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<br />l r:t�ic 1 -Ti uLr�erical ?ryes ar.Ci fc'E'
<br />fcr, re'zCid :a.(tf:c cf ;Reg::icr of
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<br />lit a Ga V.e' day Gf
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<br />o'cloc' -c a:ri
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<br />-mopage,
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<br />K'i-gisier of Oeeda
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