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PHS- ]9[IVS1 REV 4-5I STATE OF NEBRASKA' • <br />DEPARTMENT NT OF PUBLIC HEALTH. <br />DEPARTMENT OF HEALTH (� ..11 <br />EDUCATION WELFARE AND ELFARE Bureau Vital Statistics 1231" <br />of V V <br />BIRTH NO 126.. .. CERTIFICATE OF DEATH STATE FILE NO <br />1 PLAC[ 01 D[ATM I ULYAL N[LIDCNp[ I Wt.IttrN l.rN 1l rnrl,rur.wr Rt N..w HJt ..Hurt.) <br />. C.D.Tr . STATE b COUNT? NP) _ H<r11_ <br />I raska Hall <br />A urr TOWN oR wcn�oN r L1NGiH of Sur ie �In r uTr. Town. oR Lounox -- <br />w,oi <br />I <br />Uranri Tcl A",I ('wand Islam <br />/ N Or /I nor m Ampd.f Yx'r Jnd Radnn _ -- E 7TRE11 ....11, "- - _ <br />zD N57IT -LN St. Francis Hospital g(3 iiast ishton <br />15 PLACE OF 0111" hSrDt 111, L- 1TSr=E )0 HOD 1 65 RESIDENCE IN51DF CITY LIMITS' YES 1 FARM RESIDENCE? YE, <br />NO <br />—� <br />1 IIAMC o1 11re1 Lwf <br />NO <br />a D•TE AfonfA Dar Y11 <br />Ttiled!? <br />c1s[s <br />Yfrr Mr prinn LF•ona Irene Filslend <br />o 1TN Nov, 1 1960 <br />5 S[a a COLOR OR RACE T M•NPI[p [3 ME VLP MARRI[D❑ <br />[ -All OF .IRTM <br />9 AGE Iln yrnm <br />I I Y HMR 1[ NRS <br />Ym�FW� <br />Female I white ite I wI -AAFC❑ DIYDPaD _ <br />Aur. 17.. 1909 <br />IwI IHr(AaeYl <br />51 <br />Don Nm <br />Ntrw <br />1pe SUM OC[uP TIOF I(.Irr una nluu.E ennf liO1 NINOOr [uslxtss OR INDUSTRY <br />n „•I,ru mwl o/ y nrtrn/ 11/•. nr.. o rnHd <br />H RIXiNPLECL �sINr nr /orrlan rennnn <br />12 CrnLG OF- COU11H1n <br />Hpgsewi}'e - Home. <br />Parsons_. Kansas <br />U. S. <br />17, IAl— 5 NAME <br />I M11TH[R 5 ..DIN HAM[ IN. HAMf OF NUS. <br />— CR WIFE <br />f'.orrl SkinneMaude <br />r-ry <br />Smith N.erton Hilslend <br />IS WAS <br />WAS 1. <br />p Lv[R IN u s •R.C. FOPC[Sr <br />. SOCIAL SECURITY HO IF INFONMANr .tdbrw <br />1 r� u +, <br />no J no <br />IertOn Hilslend, Grand Island, Nebraska <br />18 CAUSE OF ..Al. I f nrrr only Rnr —A, per h. IAC 1.1, TAI, and Irl I • <br />"ITCRYAL [RWCCN <br />PART I DEATH WAS CAUSLD EY I� . <br />IM ."JA. TE CAUSE (1) V(�t•�iirt.41• <br />OXSET ANO DEATN <br />�yi5 t _ <br />�^- <br />n • <br />T <br />E -du nr, I /onY. <br />DUE TO (b) -•L� C i <br />ArrL <br />aeay /arum Flol, <br />_l.-�. <br />7 <br />IY n1 // aArrr rlwf <br />DUE TO (,I <br />PART Ilr 01 "G SIGNIFICANT CONDITIONS CONTRINTINL 10 DEATH [N .1 RIIATED TO THE TERMINAL DISEASE CONDITION GIYEN IN PMT 1(.) 11 WAS AUTOPSY <br />i PERFORMEW <br />C, YES❑ MCI <br />I <br />I= <br />2% ACCID[NT SUICIDI NOMICIMIMb DCSCP1— ININIURYOCCURREO IF. -nln ndurr of lnJUrY in r.el lOr rail ll of ilrm l/1 <br />20r TIM1 OF 1.1 m our AfenlA. D.Y. 5'nrl - - - - -- — - - -- <br />V INIORY <br />1E 20d IHIURY OCCURRED Mt PLACE OF INJURY Ir / m or .haul Ao 20f CITY. TOWN ON LOCATION COUNTY STATE <br />w "aL AT ❑ NO w "u[ ❑ I farm. mn,l/, ,nrrf. Rprr <br />WORN AT' <br />21 f.ff,nd.dfh, de. e.,etl /rem Q fO ����� L ..d I..l .,M yh" .Irr. .�- <br />De.lh a r.d.r 1 � ,� N(,� m on eh. d.f..f.f,d.bov...nd lO th. b.,f DI mJ Il... led/,, from Th. e. — .f.led. <br />RY <br />1226 ADD 112 <br />IIT71/t DATE SIGNED <br />jI!'Lf�IIn� <br />-T AMC or CEMETERY OR CREMATORY <br />2L BLAB.., CII.lp"I'( 23A D•T[ <br />1.1 —� /rte,'- <br />LOCATION 1E'rIY. leM'A. or roNnlYl (.R(Mr) 'g <br />Ilk <br />AEYOYAI 1.N- prrIJ11 <br />- - El2riE 1 - Ga•a!ld_ I :�]_an� _ Gra ad_Isl and Nehra aka <br />24 DATE RECD [Y RE415TR1N 1� [GISTRAN 5 SICN1111L IL NAME OF MORTUARY ADDRESS <br />NOV 14 1960 I i� / ,�� Livingston- Sondermannt Grand Island, Neb. <br />5, 19 <br />