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<br />PHS- 798(VS) REV, 4 -57 '6 `: STATE OF NEBRASKA
<br />DEPARTMENT OF PUBLIC HEALTH; DEPARTMENT OF HEALTH'
<br />EDUCATION AND WELFARE Bureau of Vital StatiStics
<br />1. PLACE OF DEATH - 2. USUAL I SISIDE�
<br />BIRTH NO. 126....._.. CERTIFICATE OF DEAT
<br />�RA
<br />p, COUNTY - � �� - a. STATE
<br />Nall nTzj -rte n
<br />b, CITY. TOWN, OR LOCATION C. LENGTH OF STAY 1111,111 t, CITY, TOW1jlbR L
<br />(ranr7 jcl av)ri I ! — rrPn I Tal
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<br />H_ . ; ......................
<br />/iU ifWi R efM1 Cd111N11011)
<br />OU Y
<br />NAME OF (If not In hospital, give street address) - d. STREET ADDRESS -
<br />HOSPITAL OR -
<br />_ INSTITUTION Franco g- L-- it.aa,,1 - - 1908 Iar Ir�i - -
<br />e. IS PLACE OF DEATH INSIDE CITY LIMITST YES NO Q C IS RESIDENCEINSIDE CITY LIMITS? YES Q . f, FARM RESIDENCE! YNSd
<br />3. NAME OF First Middle Last - r r�
<br />DECEASED - 1. DATE Month Day _ Year
<br />(Type or print) George 'Iv T 3 . 47
<br />g Zaashington. Krapp DEATH Nov. 0
<br />51 SEX 6. COLOR OR RACE 7. MARRIED [I NEVER MARRIED❑ 8. DATE OF BIRTH 9. AGE (In years IF UNDER 1 YEAR �F UNDER 24 HRS.
<br />- gale ti13te DOWED❑ DIVORCED C! Feb. Feb 1 / , lC J 649 birthday)
<br />JI less" . l x ;..
<br />100. USUAL OCCUPATION O{nCCUPATION (Give kind of lvork done 10b, KIND OF BUSINESS OR INDUSTRY 11. BIRTHPLACE (State or forerun country) 12. CITIZEN Of WHAT COUNTRY!,
<br />P Or �C of working life, even if retired)
<br />City offeeville, Kans. USA
<br />13a. FATHER'S NAME - 13b, MOTHER'$ MAIDEN NAME - N. NAME OF HUSBAND OR WIFE
<br />John Krapp ?Mary- - -- I, mar app
<br />)stable Kr
<br />15. WAS DECEASED EVER IN U. S. ARMED FORCES! 15, SOCIAL SECURITY NO. 17. INFORMANT Address
<br />_
<br />u.k -.n) I (lf yn, pier a dales of +mW) - - --
<br />Nrs. Mable Krapp, Grand Island, Nebr.
<br />18, CAUSE OF DEATH (Enter only one cause per line for (a), (b), and (c).) INTERVAL BETWEEN _
<br />PART I. DEATH WAS CAUSED BY: - - ONSET AND DEATH
<br />IMMEDIATE CAUSE (a) Cardiac failure' -
<br />Conditions, i /anV, DUE 70 (b)
<br />which gave rias /o
<br />above cause ea).
<br />stating the under•
<br />lying DUE TO (e)
<br />z rauae last.
<br />PART 11, OTHER SIGNIFICANT CONDITIONS CORMINUTING TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE CONDITION GIVEN IN PART 1(n) 19. WAS AUTOPSY
<br />i
<br />U PERFORMED! d
<br />4 YES ❑ NO ❑
<br />F 20p. ACCIDENT SUICIDE HOMICIDE 1 206, DESCRIBE HOW INJURY OCCURRED. (Enter nature of injury in Purl 1 or Part 11 of item 18.)
<br />W C1 C1 p
<br />.-J 20c. TIME OF Hour Month, Day, Year
<br />INJURY a. m.
<br />o P, m.
<br />f 20d. INJURY OCCURRED Me. PLACE OF INJURY (e. V„ in or about how, 2Df, CITY, TOWN, OR LOCATION COUNTY STATE
<br />WHILE AT NOT WHILE I form, factory, street, office Gdg„ etc,) - I
<br />WORK ❑ AT WORK ❑
<br />21. 1 attended the deceased from to and last saw her alive on
<br />Death occurred at n on the date stated above; and to the best of my 4nowledae, from the causes stated.
<br />22a. SIGNATURE (Degree or title) I U2b. ADDRESS 22e, DATE SIGNED -
<br />Carl ],aggaire 14.D. Gland Island, Nebr. I Nov•30-47
<br />23a. BURIAL, CREMATION. 238, DATE 23e, NAME OF CEMETERY OR CREMATORY - 23d. LOCATION (City, lows, or county) (Stale)
<br />R� "�r�`�� "I /y) + Dec. 47 3 � I Shelton Cemetery � Shelton, Neb.
<br />21, DATE RECD, BY REGISTRAR �25, REGISTRAR'S SIGNATURE ( 26. NAME OF MORTUARY
<br />ADDRESS
<br />Apfel- Butler- Geddes
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