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Conditions tf any DUE Tb (b) <br />OT.", rus <br />I <br />Si u hick MWs o q [ above Cause la) <br />v0 / stating thg under <br />V ? ss lying cause last I DUE TO (o) <br />PART II OTHER SIGNIFICANT CONDITIONS CONTRIBUTINS TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE CONWTION GIVEN IN PART I(q) 19 WAS AUTOPSY <br />AVM Sj I F v PERFORMED/ <br />i^ YES ❑ NO ❑ <br />4 <br />F AGCIpENf SUICIDE HOMICIDE 206 DESCRIBE HOW INJURY OCCURRED (Ever► nolutt of injury IR Part for Part 11 o /LtsrH t! ) <br />yy, ❑ ❑ ❑ <br />7� 20e TIME OF Hour Month Day Year <br />INJURY a m <br />WD in <br />I 2Od INJURY OCCURRED 1 We PLACE OF INJURY (e g in a about home 12Df CITY TOWN OR LOCATION COUNTY STATE <br />« WHILE AT NOT WHILE farm factory sired ojiu bldg etc ) <br />y WORK ❑ AT WORK ❑ <br />21 f attended the deceased from to and last saw her alive on <br />him <br />Death occurred at v on the date stated above and to the be.f of my knowledge from the causes stated <br />22C 416MATURS (Degree or Ikle) Z26 ADDRESS j ZU DATE SIGNED <br />=s Robert Re Geer, Me D. Grand slam, Nebr. <br />s y 23. BURIAL CREMATION, Z3B PATE 2k NAME of CMETERY OR CREMATORY 23d LOCATION (City SOWN p county) (Stoic) <br />vq M REMpV♦]� {S_P6�l � 5 -15-60 � Grand sland Ctemetery � Grand Island. Nebr* }� <br />x. N DATE RjEjCO BY REGISTRAR 12L REGISTRAR S SIGNATURE 24. NAME Or MORTUARY ADDRESS <br />Apfel- Butler- Geddes; Grand eland <br />°s /r <br />do <br />State cf Nebraska <br />Ccun(y cf i all j ss <br />Erte►cd o-T, ;,L nerml lyd--s and f led <br />fcr recc ►d I1 LifCg cf 1Re�ter of <br />L cells en t a - �=th_- _ . clay of <br />- 14,ixch _ - 19_ 63- at . 9___ - - J J, <br />o c'oc c ea 1 !LO_ - m Hu ss _A.__M v <br />aid 1c%.0I _`Cd In Cco c 11 ` of <br />_ - 14i.scel. _- at page <br />J Reglster &Deeds - k <br />By= ° --------- <br />' <br />Bees ° 1�7 pd. Deputy <br />r P 4 ; - --- <br />r � <br />� r f d <br />l r <br />PHS 798(VS) REV f 57 3 <br />DEPARTMENT OF PUBLIC HEALTH <br />STATE OF NEBRASKA <br />DEPARTMENT OF HEALTH P* <br />= <br />EDUCATION AND WELFARE <br />Bureau of Vital Statistics prf01 -Butt r F e Home <br />CERTIFICATE OF DEATH <br />y, <br />BIRTH NO 126 <br />STAT FI <br />- <br />1 /LACE OF DEATH <br />2 USUAL RESIDENCE(Wh- d—.d = www) <br />V <br />o. COUNTY <br />Hall <br />a STATE <br />Nebr <br />a� _ <br />3 <br />h CITY TOWN, OR LOCATION <br />a LENGTH Of STAY IN III a CITY TOWN ON LOCATION <br />11i <br />' Grand Island. <br />I -- Grand Island <br />_ <br />w <br />(!f no( in,Thospttat give street <br />d NAME Of <br />address) d STREET ADDRESS <br />910 Ji <br />x <br />OR <br />INSTITUTION 305j N. pine <br />2627 We 1st <br />a IS PLACE OF DEATH INSIDE CITY LIMITS? <br />YES NUL3 t IS RESIDENCE INSIDE LIMITS? YH01� if f FARN RESIDENCE? YES(], <br />t <br />— aO <br />I <br />° <br />"is <br />1 <br />NAMR OF Ford <br />DECEAGEs <br />-CITY <br />Middle lost l4 DATE Month Dar I Year B <br />OF <br />14 <br />aQ <br />l7ypr or print) Archie <br />L. Hiatt DEATH May l2g 1950 <br />f <br />; <br />g ; <br />i <br />E SEX <br />M <br />- <br />6 COLOR OR RACE <br />1 W <br />7 MARRIED][] NEVER MARRIED❑ 6 DATE OF BIRTH 9 AGE I/n yrlf F UNtKN1 YEAR LINDEN >'A HRi <br />A=rlAday) ,Yantly Dy* Xorq <br />WIDOWED DIVORCED( 2 -4 -1890 b0 vrs I <br />ti A <br />)Dq USUAL OCCUPATION (Give kind o /cork done <br />life if retired) <br />10b KIND OF BUSINESS OR INDUSTRY <br />11 BIRTHPLACE (State or foreign country) 12 GTIMM OF WHAT COUNTRY1 a <br />a a tt <br />du Ing mod of working even <br />Laborer <br />general <br />Hampton, Nebr. USA' <br />rwy <br />r� <br />t <br />1,71 FATHER S NAME ' <br />13b MOTHER S MAIDEN NAME <br />14 NAME OF HUSBAND 00 WIFE <br />FI <br />Robert Hiatt <br />Frances f — <br />Frances <br />I Elsie V. Hiatt <br />r+k$ <br />' <br />IS WAS DECEASED EVER IN U S ARMED FORCES? 16 SOCIAL SECURITY NO <br />INFORMANT 4ddress <br />t <br />d <br />�Ia <br />Ire. a. =a-aWel I <br />uf.. e.r.wr..dataq/.srtw.l <br />-- <br />117 <br />Mrs. Elsie Hiatt. Grand Island=, Nebr, <br />w e3 <br />= <br />16 CAUSE OF DEATH [Enter only one cause per line far (a) (b) and (c) ) INTERVAL BETWEEN <br />ONSET AND DEATH <br />,p <br />■.I� <br />q <br />PART 1 �DLATN WAS CAUSED BY. <br />r <br />Coronarlr occlusion <br />2 <br />1 I MMEDIATE CAUSE (a) <br />Conditions tf any DUE Tb (b) <br />OT.", rus <br />I <br />Si u hick MWs o q [ above Cause la) <br />v0 / stating thg under <br />V ? ss lying cause last I DUE TO (o) <br />PART II OTHER SIGNIFICANT CONDITIONS CONTRIBUTINS TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE CONWTION GIVEN IN PART I(q) 19 WAS AUTOPSY <br />AVM Sj I F v PERFORMED/ <br />i^ YES ❑ NO ❑ <br />4 <br />F AGCIpENf SUICIDE HOMICIDE 206 DESCRIBE HOW INJURY OCCURRED (Ever► nolutt of injury IR Part for Part 11 o /LtsrH t! ) <br />yy, ❑ ❑ ❑ <br />7� 20e TIME OF Hour Month Day Year <br />INJURY a m <br />WD in <br />I 2Od INJURY OCCURRED 1 We PLACE OF INJURY (e g in a about home 12Df CITY TOWN OR LOCATION COUNTY STATE <br />« WHILE AT NOT WHILE farm factory sired ojiu bldg etc ) <br />y WORK ❑ AT WORK ❑ <br />21 f attended the deceased from to and last saw her alive on <br />him <br />Death occurred at v on the date stated above and to the be.f of my knowledge from the causes stated <br />22C 416MATURS (Degree or Ikle) Z26 ADDRESS j ZU DATE SIGNED <br />=s Robert Re Geer, Me D. Grand slam, Nebr. <br />s y 23. BURIAL CREMATION, Z3B PATE 2k NAME of CMETERY OR CREMATORY 23d LOCATION (City SOWN p county) (Stoic) <br />vq M REMpV♦]� {S_P6�l � 5 -15-60 � Grand sland Ctemetery � Grand Island. Nebr* }� <br />x. N DATE RjEjCO BY REGISTRAR 12L REGISTRAR S SIGNATURE 24. NAME Or MORTUARY ADDRESS <br />Apfel- Butler- Geddes; Grand eland <br />°s /r <br />do <br />State cf Nebraska <br />Ccun(y cf i all j ss <br />Erte►cd o-T, ;,L nerml lyd--s and f led <br />fcr recc ►d I1 LifCg cf 1Re�ter of <br />L cells en t a - �=th_- _ . clay of <br />- 14,ixch _ - 19_ 63- at . 9___ - - J J, <br />o c'oc c ea 1 !LO_ - m Hu ss _A.__M v <br />aid 1c%.0I _`Cd In Cco c 11 ` of <br />_ - 14i.scel. _- at page <br />J Reglster &Deeds - k <br />By= ° --------- <br />' <br />Bees ° 1�7 pd. Deputy <br />r P 4 ; - --- <br />r � <br />� r f d <br />l r <br />