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u PHS- 799(VSI REV 4 -57 4 STATE OF NEBRASKA <br />W DEPARTMENT OF PUBLIC HEALTH, DEPARTMENT OF HEALTHC�( *PT <br />EDUCATION AND WELFARE Bureau of Vital Statistics Apfel <br />_But J.e Furie al Home r; BIRTH NO. 126 .... .--- CERTIFICATE OF DEATH STATE L <br />€j 1. LAC[ DEATH 2. <br />0 R[f10[NC[(I►Mn t.a•�.df FI- <br />i • COUNTY TY a. •. STATE UN <br />Hall uebr <br />W A. CITY, TOWN, OR LOCATION [. LENGTH OF STAY IN IA C. CITY, TOWN, OR L Grand sland 14 Yra Ge lI�1 aY,t�_ <br />n d. NAME OF (If not in AaApital, give street address) d. STREET ADDRESS <br />HOSPITAL OR <br />ZD z INSTITUTION St. Francis Y.osrital_ `7 ?v. 17th _ <br />x 2 C t.IS PLACE OF DEATH INSIDE CITY LIMITS? YES ❑ NO ❑ t. IS RESIDENCE INSIDE UTV LIMITS+ YES Q / FARM RESIDENCE? YES r' NOO NO E, <br />41 MANE Of <br />First �.Nidd/t Loll -- -- -- <br />a DECEASED 1 GATE MonlA ) vy 1 "ra <br />3� (rype ar print) Alfeed Leth OF <br />DEATH -4 —�13 <br />Q W 5 SEX 6 COLOR OR RACE 7 6 GATE OF BIRTH 9 AGE IIn years IF UNDER I YEAR <br />a I MARRIED by -NEVER MARRIED <br />❑ _ -�_ _yf UNDER :t Iw5 <br />N y r4 fA iJyf �] { Ipj� otAday) .v an U. D.A. <br />dI a WIDOWED ❑ DIVORCED 4 -23 -1 C' I / yrs <br />a it ION USUAL OCCUPATION ICiot kindo /u ork done I IDA KIND OF BUSINESS OR INDUSTRY I B[R 74PLACE 4S(afe or Jor .gn r' n!I, y) )2 CRIKN OF XHAf COUNTRY <br />W dtp(iu ywt of u,o4Ainp lift , t,tn IJ retired) ne�ired rarraer <br />Agriculture Elba, Nebr. USA <br />iy-. E y 130. FATHER S NAME 13b. MOTHER S MAIDEN NAME — - - <br />14. NAME OF HUSBAND OR WIfE <br />3� "ov John Leth Knren 'Varie Jensen Jennie Leth <br />'O FCC C )5 WAS DECEASED EVER IN U S ARMED FORCES, 16 SOCIAL SECURITY NO 17 INFORMANT Address <br />� ^, [ I P... I . —4—.1 J/ r�r o�u. uur w dale o /.m,r.1 <br />507 -36 -2963 Mrs. Jennie Leth; Grand Island, Neer. <br />� no �r <br />'z. R <br />—:j 3 18 CAUSE Of DEATH (Enter only one cause per lint for (a), (G), and (c)) INTERVAL BETWEEN <br />00-5 W PART I DEATH WAS CAUSED BY <br />—I W' 1111' ' IMMEDIATE CAUSE (a) Acute coronary ccculsier ONSET AND DEATH <br />1./�.a W.O <br />0 ya E'ondihona, IJany, 1 DUE TO (G) <br />01 " o abot, putt nsq to 11111 _ <br />Gi o � aGott -aasr u), <br />C "op atullnp (ft Under• <br />iri s VA z lying !oast last DUE TO (c) <br />' p U D PART 11 OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE CONDITION GIVEN IN PART 1(4) 19 WAS AUTOPSY <br />��W•� ~ PERFORMED? <br />:si« and U <br />YES ❑ No <br />20a ACCIDENT 5UICCIIOE HOMICIDE 20b DESCRIBE HOW INJURY OCCURRED (Enter nature o /Injury in Part I or Part 11a /item 18.) <br />Qi a~i I"F^ W <br />Ewa a m <br />rr W < 20C TIME OF 11aur .Vonlh, Day, Year - - - -- <br />INJURY a. m. <br />P. In. <br />u o r i 20d INJURY OCCURRED {I 20e. PLACE OF INJURY (e. I , in or abotrf home, 201 CITY, TOWN. OR LOCATION COUNTY STATE <br />a 4 WHILE AT C] NOT WHILE r'T I /arm, factory. a!rree, oQice N O , ete,) I <br />y a WORK AT WORK u <br />I_ y 21 1 attended the deceased from to and /eat saw her <br />h,rn a /iv. on <br />a O L Death occurred at _ _ m on the date stated oboe e, and to the best of my knowledge, from the causes stated <br />m Z2a SIGNATURE (Degree or (life) Ub ADDRI SS <br />I22r DATE SIGNED <br />n� <br />G. W. Graupner, 14. D. Grand Island, Nehr. <br />t 23a BURIAL CRfMATroN, 23A DATE 23C NAME OF CEMETERY OR CRLMATORY 23d LOCATION I t•dy, fou n, or rotj,/y' (11we) <br />R MOVAL 1 fi /yl <br />aria 2 -7 -63 Grand Island Ce1-:ete Grand I_s_land e _ _r_r_._ <br />Tr <br />24. DATE RECD BY REGISTRAR 125. REGISTRAR S SIGNATURE 24. NAME OF MORTUARY L.. ADDRESS <br />'/J r, , r ) I Apfel- Butler-('.eddes, Grand Island, ?'ebr. <br />IU <br />rs <br />`7z9/ <br />S <br />ell <br />:r o! <br />April <br />1st - cF <br />63 <br />�5 a: ; <br />-3 <br />11 <br />Miscel <br />I :y - - - - ---_ -' <br />- • <br />pd. <br />n i <br />`7z9/ <br />