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PHS- 798(VS) REV. 4 -57 <br />EDUCATION AND WELFAREEALTH, <br />BIRTH No. 126 ........ <br />PLACE 01 DEATH <br />R. COUNTY <br />STATE OF NEBRASKA <br />DEPARTMENT OF HEALTH <br />Bureau of Vital Statistics <br />CERTIFICATE. OF EA <br />i�A.re d.a. <br />i <br />b, CITY, TOWN. OR LOCATION I t. LENGTH OF STAY IN 16 ' e.'CITY. TOWN, OR L kV <br />Grand Tsland j� v-rs. grand Ia anri <br />d NAME OF ! at ' A s 'tat ivt steed addnse) d. STREET ADDRESS <br />all <br />.dww.wn <br />HOSPITAL OR (/ IT in as_ <br />INSTITUTION Sy , Frans<is�3QS. �t,a1 437 W 1 1 J.I, 1❑y7�,� , <br />e. IS PLACE OF DEATH INSIDE CITY LIMITS? YE NO ❑ t. IS RESIDENCE INSIDE CITY LIMITS? ES S If. FARM RESIDENCE? YES Q. <br />3. NAME OF First Middle Lost 4. DATE [) Month Day Year - <br />DECEASED OF <br />(Tppe or print) Emil Henry Kroeger DEATH An.•. 18 63 <br />S. SEX 6. COLOR OR RACE 7. MARRIED ® NEVER MARRIED ❑ S. DATE OF BIRTH 9. AGE (In pear# R UNDER 1 YEAR V UNDER 26 HRB, <br />lost birthday) M-8h. I D.A. N.rn Alin. <br />Male White WIDOWED [I DIVORCED_ Dec. n 90� 7 <br />10s. USUAL OCCUPATION (Gist kind o1work done IOb. KINDOF BUSINESSOR INDUSTRY 11. BIRTHPLACE �(State OI fortipR country) TZ. CITIZEN OF WHAT COUNTRY? <br />du•ing most of working life, even If retired) <br />Machanist Railroad Hall Coun -W. Nebr. USA <br />134. FATHER S NAME 13b. MOTHER'S MAIDEN NAME 14. NAME OF HUSBAND OR WIFE <br />Rena► Kroeger Emma Schultz Amy Kroeger <br />15. WAS DECEASED EVER IN U. S. ARMED FORCES? 16. SOCIAL SECURITY 140. 1 17. INFORMANT Address <br />(Yr -, no. w unk no.n) (!f om eiw Ww w date. of -i-) <br />Jo 1 t12 -07 -1631 Amv Kroeger. Grand Island. Nebr. Wife <br />16. CAUSE OF DEATH (Enter only one cause per lint for (s), (b). and (e).) INTERVAL BETWEEN <br />PART I. DEATH WAS CAUSED BY: ONSET AND DEATH <br />IMMEDIATE CAUSE (a) Bronchozinis C A and eeneralized metastices <br />9 <br />`F <br />V <br />LL <br />F <br />W <br />VJ< <br />V <br />a <br />W <br />t <br />Conditions, if any. DUE TO (b) - <br />whicA pant 4, to <br />above cause a). <br />stating the under. DUE TO (ell <br />lying cause loat. <br />PART II. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE CONDITION GIVEN IN PART I(a). <br />200. ACCIDENT SUICIDE HOMICIDE 2016. DESCRIBE NOW INJURY OCCURRED. (Enter nature o /inJUFF in Pod I or Port II of item 1EJ <br />❑ ❑ ❑ <br />20e. TIME OF Hour Month, Dag, Year <br />INJURY p. a. m. , <br />n. ' <br />19. WAS AUTOPSY <br />PERFORMED? <br />YES ❑ NO ❑ <br />20d. INJURY OCCURRED 20t. PLACE OF INJURY (t. y in or drew hone, CITY, TOWN. OR LOCATION COUNTY STATE <br />WHILE AT C] NOT WHILE C] I form, factory, sired, oaks bldg., dt.) 1201f. <br />WORK AT WORK - <br />21. I attended the deceased from , to And lest sew her Olive on <br />hi <br />Death occurred at in on the date stated above; and to the best of onj knowledge. from the causes stated. <br />22s. SIGNATURE (Degree or title) Ub. ADDRESS 22e. DATE SIGNED <br />C. He Maggiore M.D. (Grand Island. Nebr. <br />23s. BURIAL. CREMAIION. 23b. DATE 23e. NAME OF CEMETERY OR CREMATORY 23d. LOCATION (City, town. or County) (State) <br />Bux�iat"ec ' I k -20-63 I Grand Island Cemetery I Grand Island Nebr. <br />24. DATE RECD. BY REGISTRAR 12S. REGISTRAR'S SIGNATURE 1246 NAME OF MORTUARY ADDRESS <br />Apfel- Butler - Geddes) Grand Island, Nebr, <br />9 <br />`F <br />V <br />LL <br />F <br />W <br />VJ< <br />V <br />a <br />W <br />t <br />Conditions, if any. DUE TO (b) - <br />whicA pant 4, to <br />above cause a). <br />stating the under. DUE TO (ell <br />lying cause loat. <br />PART II. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE CONDITION GIVEN IN PART I(a). <br />200. ACCIDENT SUICIDE HOMICIDE 2016. DESCRIBE NOW INJURY OCCURRED. (Enter nature o /inJUFF in Pod I or Port II of item 1EJ <br />❑ ❑ ❑ <br />20e. TIME OF Hour Month, Dag, Year <br />INJURY p. a. m. , <br />n. ' <br />19. WAS AUTOPSY <br />PERFORMED? <br />YES ❑ NO ❑ <br />20d. INJURY OCCURRED 20t. PLACE OF INJURY (t. y in or drew hone, CITY, TOWN. OR LOCATION COUNTY STATE <br />WHILE AT C] NOT WHILE C] I form, factory, sired, oaks bldg., dt.) 1201f. <br />WORK AT WORK - <br />21. I attended the deceased from , to And lest sew her Olive on <br />hi <br />Death occurred at in on the date stated above; and to the best of onj knowledge. from the causes stated. <br />22s. SIGNATURE (Degree or title) Ub. ADDRESS 22e. DATE SIGNED <br />C. He Maggiore M.D. (Grand Island. Nebr. <br />23s. BURIAL. CREMAIION. 23b. DATE 23e. NAME OF CEMETERY OR CREMATORY 23d. LOCATION (City, town. or County) (State) <br />Bux�iat"ec ' I k -20-63 I Grand Island Cemetery I Grand Island Nebr. <br />24. DATE RECD. BY REGISTRAR 12S. REGISTRAR'S SIGNATURE 1246 NAME OF MORTUARY ADDRESS <br />Apfel- Butler - Geddes) Grand Island, Nebr, <br />