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« PH$ 798(VS) REV d 57 STATE OF NEBRASKA 7,0 - X6 <br />DEPARTMENT Or PUBLIC HEALTH IMPARTMENT OF IiEALTR <br />EDUCATION AND WEVARE Bateau of Vital S tistic$ <br />BIRTH NO 126 CERTIFICATE OF DEAT ATE <br />1 PLACE OF DEATH L us A NE <br />_ d e COUNTY dams' ��e_ r all. <br />"B St D CITY TOWN OR LOCATION t LENGTH OF STAY IN 1A 1PITY TOW LOCATK?N <br />Hastin>KS ,Crrand Island <br />w d NAME Of (!/ not IR Aospltat pNVt stud oddress) 'd STREET ADDRESS <br />HOSPITAL OR <br />r.4 x INSTITUTION Ingleside State Hopital 1315 Ito, HuttOrt Qp, <br />0 e IS PLACE OF DEATN INSIDE CITY LIMITS? YES(] N t IS RESIDENCE INSIDE CITY LIMITS? ES �f FARM RESIDENCET YES i s Non NO <br />j •3 NAME Of I$rat Waddle Last 4 DATE Month Day Year <br />DECEASED v. tf p Or t1� (/� <br />(type or print) Fern 3' Eaton DEATH A"s 2 60 <br />5 SEX S COLOR OR RACE T MARRIED ej NEVER MARRIED ❑ I 6ATL OF BIRTH 9 AGE (le Vtaq K UNpER (YEAR UNDER >A Leos <br />fmt <br />I DvlAdoy) YvnlAr D.N Hwn Nu <br />c!t W*1 A White WIDOWED ❑ DIVORCED <br />104 USUAL OCCUPATION (Give kind a/ work done lob KIND OF BUSINESS OR INDUSTRY it (S/a!t or /orelpe town y) IZ CITIMM (if wNAT COUNTRY? <br />r.. ` W du Inc most of workent lift even if retired) ` <br />NQ33 eawl f a H�xnl Qck,_Nwhr 1I,�IJ <br />1, m� 13e FATHERS NAME 13D MOTHER S MAIDEN NAME OF HUSBANQ OR WIFE <br />1tvaratt Rrfk <br />c^ QFp) Etha pVN1 <br />IS WAS DECEASED EVER IN 4r. FORCES? <br />10 SOCIAL SECURITY NO 1 IT IN /01tMAMT 3114 ,( I <br />y (Y • no w u 1noWn1 (1/ yn 0 re �.r w d.ks o1--) } <br />Z a Ra 1 nh itat nn _ RrAnd <br />LL v i I / - yl �/Y�Y.Y�r•iF TI1�� ���� I 111 <br />9 5 IS CAUSE OF DEATH (Enter only one CoaAt per line for (A), (b) end (t) ) INTERVAL BETWEEN <br />CC s PART I DEATH WAS CAUSED BY ONSET AND DEATH <br />6S IMMEDIATE CAUSE (a) _Bronehopnellmont"k <br />J q <br />.I Conditions I /any DUE TO (b) <br />which poet rtrF Ip <br />m about couse s <br />e`7 uO stating the under DUE e <br />TO () <br />> V lying coast Lod 1! WAS AUTOPSY <br />PART 11 OTHER SIGNIFICANT CONDITIONS COMMINUTING TO DEATH BUT NOT ROUTED TO THE TERMINAL DISEASE CONDITION GIVEN IN PART 1(4) PERFORMED? <br />YES O te00 <br />��7 = 2W ACCIDENT SUICIDE HOMICIDE 20h DESCRIBE NOW INJURY OCCURRED (Enter nature afin}urE ill Part tar Part lI o/ Ite>A 10 ) <br />20e TIME of Hour Mantit Day Year <br />INJURY a m <br />0 p m <br />s, o 20d INJURY OCCURRED 21k PLACE OF INJURY (t I In or &W Apme 201 CITY TOWN OR LOCATION COUNTY STATE <br />r WHILE AT [] NOT WHILE O lane factory street ah4ce bldt d0) I <br />y WORK AT WORK <br />V <br />21 I attended the deceased /rorn , to And lost saw A r ahve on <br />o Death occurred at sn on the dab stated above and td the best of mp Anowled /e from the causes stated <br />to a 224 SIGNATURE (Degree or lkk) 220 ADDRESS I ZZe DATE SIGNEQ <br />� y� Dr. K tiForster M.Dy astin[s. Nebr p <br />,o w ]y Vs BURIAL CRrMATION M DATE 231 NAME OF CEMETERY OR CREMATORY ZU LOCATION (CNty, town of county) (State) <br />REMOVAL (Spetlfit <br />ra Bur{ a1 �.-5 dratted Island Nebr► <br />L4 I`y 7i N 24 DATE RECD SY REGISTRAR 2S RE NSTRAR S SIGNATURE 2L NAME OF MORTUARY ADDRESS <br />ApfoX- Butlar- Goddess Grand Talandi Nebre <br />