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PHlawlVelRN.� -sii -� -- -- STATE -OF NEBRASKA — -- • 7 <br />DEPARTMENT Or PUBLIC HEALTH, DEPARTMENT O HEALTH 02306 <br />EDUCATION AND WELFARE BYEN�E.�a( y�x1 LL1Sta �� 1 - <br />BIRTH NO. 128........ CERTIFICAYC .1 MATH STATE Flu NO. <br />-1. PLACE or our. I ....I Kf1o[NCB IN`— Ar.r.r 1•r/ .=5— RrJrr wyN.yrr.r.l <br />s Cou.n Adams n . 1 _ /) A "A a couNTr <br />'ah ra k'� ABame <br />B. CID'. TOWM. W IOCATIDM I r LENGTH OF STAT IN IA [ Cl- T.... DA a rN <br />Hastines.. KO years, Faetings. <br />I. HAME or 1/f •AM It Yapur. a •HI •��VA) Al STREET ADDRESS <br />11�13TITUTq 3 'a west of 1?astir�gs.l ''asting =f, _ <br />.. K r Aa Or DEATH INSIDE CITY LIMITSI YES NO e. IS RESIDENCE INSIDE CITY LINITSr YES �J. FARM RESIDENCE? THOS <br />NO _ <br />MYIYI[ of Nrd AIMIb I- wT, AEM I A Dy Y.r, <br />"CUM <br />17YP. np11d) hliese A. rt,arie- aAT. 1P.rcl',. ?R. 1961• <br />{ SEE { COLOR OR RACE 7 HARRIED ❑ NEVLR MARRIED❑ B pAIE ar RIRTN -- S DE I7A Year TM UwuI YEAR ur,m M"b. <br />C IAN AFIN 14 Yr.rY I DrAr �wr� YY <br />Female � 111tP, WIUDWLD X DIVDRCED_ 1'ov '0 IF77- <br />IOM. USUAL OCCUVATMMI IOW llNf Af Wort for Ilb KIMD OE BD$INESS OR INDUSTRY 11 RIATNFIDE 19d. r for.gN —NE,rI H GIImI DE wwT pyY111Y1 <br />/.•IlouseIM SAN A( kiN1 hp, rA.N V r.flydl <br />wif,.. 7e? FaTm IinmP7 S�.mre,r,_ 7 A _ p c s D <br />IL. EAT... S NAM[ LIB. MOTHER S MAIDEN NAME TN NA <br />. ME OF HUSBAND OR wlrE <br />Henry Halves, I Fzank. (deceased): <br />15 WAS DECEASED EVER W U s ARMED F?.CLI 11 SOCIAL SfEURITT 110 I" INEORYYIT Adb.. <br />IF.. r.;..E I Ilr yr. r•H wr ryH•.rr - <br />no J ''one= ]irs Rena `wade. Hastings. 1rebrasjtaM <br />IB DAYK M DEATH IEYn "II Av rour pr M. Ie1, oI (tl.l <br />\ .ART I DEATH WAS CAUSED Br <br />YMCDp CUM (A) <br />fi <br />I Ts-eil <br />Du ED <br />YYYy .four (W DUE TO ._ <br />PART H OTHDI SMNUWJAI f — C4A , I,IRITTIIN ro DEAIN arI —11H .T 1N_E 1fAid— -MAK COIMITVIN GIVEN Y PART I(NI 'WA ALIT pr <br />TIES ❑ ND❑ <br />M. ACCIDENT SUICIDE HOMICIDE 211 M.RK NOW NJUROCCURRED P.N I r PAN 1144.. II) <br />; <br />❑ ❑ ❑ <br />no TIME of "AN, .RNA. I". Y. <br />— - <br />WIT . <br />.... <br />Tod INJURY OCCURRED M; RICE a INIUAY Y E} IN n d� LOW, I7M CIT1. TOWx, W LOCATNMI wuxn snn <br />WMIA AT ❑ NOT WHILE Q I hr.. fw.rv. deed.. HIS.. N..) <br />WORM AT MORE <br />dKIAAAd ). �—/S f. —2T_. 1 end ful ur = AliV- OR �C 9L!U'R <br />Af AocurrAd j/L./n on hA dAIA At,s W, Abor.. And Ao IM boot .1 nV A rf.d/., 1— 1h. uuAw At.t.I. <br />BI TYr' O.Irr; dti, n m ADD . WTE SIGNED <br />D{ ITAM r). NAME Or CEMETERY OR CREUASIWAY 2 L T IivE, frAR. r roYNTEI ($W) <br />i f�;3A lt- j.r(r]' • }cvi ew CPme+ astin e, Nebraska,, <br />X DA K i RFrjrl A{ b. 'f SIGNATUK I M..AYE DE MORTUARY ADDRESS <br />' ���t I Brand Mortuary. Hastinee. Nebraska. <br />