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` STATE OF NEBRASKA—DEPARTMEN'I'OF IiEALTH
<br /> �,�', ���f' Qureau of Vital Statistice ^ 7 � �, �, � 6 / �
<br /> ry CERTI FICATE OF DEATH � ��[. ,,,,,,,,,„�,,,,.
<br /> DE A ED—NAME n�si rioou �•s� SEX � DATE OF DEAtM �Mo�rw, o•r,�tu�
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<br /> ACE WNITl�NlG�O���l��UNJMDI�N� AGE-1�3T uwoe. � .e.� u�oe��o.r DATE OF 61RTM�Mo«�r, o.r, COUNTY OF DEATH
<br /> 11C. 1 SIlCIII 1 �I�TND�I 1�fA�l l MOS. OAYS MOU�S MIN. �E��1
<br /> � U. s. s� s� � � cq �. 1 11
<br /> CITV,TOWN,OR IOCATION OF DEATH ��s�oe un ur�*s HOSPITAI OR OTHER INSTI TION—NAME ur no��..ur�e.,ave snen,r+o�u..�e■i
<br /> . 1 S�fCI�Y Y!5 O�NO • � .
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<br /> STATE OF 61RTl1�n r.o�u+ u.s...,r+...e CITREN OF wHAT OUNTRY MARRIED,NEVER MARRIEO, ' SURVIVING SPOUSE��r.+ut,crve r.ioew nu.e�
<br /> couwnr� WIDOWED,DIVORCE��sr[cur i ..
<br /> t. �, � �. 10. 'v' � 11. "�T �,
<br /> SOCIAL SECURITY NUM6ER . USUAI OCCUiATION IG�VE[iMD O�WO�[DON[ou�iwp.(oi�o� KIND Of 6USINE55 OR INDUSTRV
<br /> M'OIRiNG Ufl,lMfN u�einto�� '-
<br /> � o ��. t �ar-^e t�' u► Farr:iin
<br /> RESIDENCE—STA E COUNTV CITY,TOWN,OR IOCATION ��sioe cin iu.�rs STREET AND NU/.�6ER
<br /> IS�EC�/�Yt5 O�NOI _
<br /> i�. 'gr i�n ��t . u� n1r�}?2n i�a -;*es i�. ----
<br /> iATMER—NAME 1��31 riDDIE u5i MOTHER—MAIDEN NAMf ���5� �+ioD�e U31
<br /> ,s. , n rn land �S► Jenetta -- 1�'c'`aster
<br /> 11.WA5 DECEASED EVER IN U.S.ARMED FORCE57 INFORMANT—NAME—REUTIONSHIF—MAIUNG�DORE55 �snen o��.r.o.�o.,or.o��owH,sr.�t,au�
<br /> •(Y•�.ne, un�nown) I (11 r...gl.•.a.a�d dore�of.erv�c•) .
<br /> - , ��.?�rs I��ettie L•'neland �:'ife Doniohan T;�ebr. .6�� 2
<br /> ♦nwuw.l u+rew��
<br /> PART�I. DEAT11 WAS CAUSED 6Y: �ENIfR ONIY ONE UUSE PER IWE FOR(oJ,(b�,AND �c)� �erwtew oNit�•No Dt�IM
<br /> �� - u...co�.re e•uie 7 '�
<br /> lol '�` 7 G 4'�f� �/il�� l '� UiL�
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<br /> ���tM��c.re ,ise �o (bl Qf l�� � I O./'�1LO_l_� page��.-----
<br /> irueoi.0 uuse im, � oue*o,o��s•eo�seoue..c[or-. ' '
<br /> ""�"° �"' ""�'•. Hall CountY, Ne raska
<br /> inwc uus[ us�
<br /> '`) WAS TME�E A AUTOPSY IF YES �'t�! /iHDIMG3 CON-
<br /> ►A�T 11. OTMEII SIGNIfICANT CONDITIONS�.CONDIiIONS CONTRIlUTING TO DEATH!Ut NOT�FUTED ►Atl III.li FE/MIE,
<br /> i0 CAUSE GIVEN IN►ART Ila) ►�EGNANCT IN TME.►AST J MONiNS1 ��es ot NO� OD DlwTM�0lft�rl�+�wG C�uS!
<br /> ,es o r+o c ia No i»
<br /> ACCIDENT,SVICIDE,MOMICIDE, DATE F INIURY �.o�+�,o••,+f•+� HOUR NOw INIURY OCCURRED �E�rt�...iu�e o���w�+i..r,n i o�r.n u,rce.+��i
<br /> OR UNDETERMINED isr[urn �
<br /> � �� � 20�. M 70d
<br /> INIURY AT WORK PUCE Of INIURY•r noM[,�.�+,sneer,r.po�•, IOUTION i snen o��.r.o...o.,un o��owH, s�.+[i
<br /> 1 srec�rr 1Es o�wo l O���ce�iDG.,��� �s�K�n 1 � '
<br /> 70� � 7�
<br /> CERTIfIUT10N— Ma+�� o.r .e.. .or.r� o... re.� w"o o�rh�W�o.�f••��e.��� �oo./�*eoc�n�w THe pNOu.'OCN�RED o,n,�.�o�ro me�es�
<br /> ►Hrsiu.r+: Ao�..r a�.o.+�eoee,oue
<br /> TO �
<br /> � •^°�"""' 9;, 2p 74 „� 10 25 74 ,,, 10 16 74 ,�, Did not:�. 7:40 M �O THt UUSe�Si i��rtD.
<br /> jl�. DFCf�llD i�Ora �
<br /> CERTIFlUTION—MEDICAI EXAMINEN OR CORONER:or.rHt�•sis or r�t �ou�w ot•r� !N!D!C!DlHI wA3��OHOUwCEO DF�D �
<br /> ea�r�w�no�+or me Wo���+o/O��Me i�+rtSTiG�1�ON,�M Mv o��M�Ow, . Mor1 0�� *t.� Mou�
<br /> oe•rH occu��to o..me owit•wo oue ro��F uuse�s�s�•�eo 7'�F� A M 211 1 'z 5 '][} 7•(}Q �.
<br /> 7ta �` DFp�ilfe nne ' DATE SIGNED�Mo.+�w,o.r,re.0
<br /> CERTINER—NAME mre o�r���q SIGNA �
<br /> �� 7n /' /�—c� ��,' 't✓ r�< 10 29 74
<br /> :7. �' a ''r'e ' cm o.,owH s,.re ei.
<br /> MMIING ADORE55—CERIIHER )��fEi O��.�.o.r.o.
<br /> 17d 7 �.� � . C =� �`P
<br /> EURUI,CREMATION,REMOVAI CflaEiERY OR CREGUTORY—N�ME IOCATION un o.ww� sur[ .
<br /> i sreurv� �- .
<br /> z�o • ��b ��• m , ��<. Doniphan, ;orr
<br /> DATE �rONrw,Dwr,�lw�l fUNERAI HOME—NAME AND ADDRESS �`4��tet O��.�.0. No.,C�tr-o��Ow�., S���t,tir
<br /> 2N C-?_8- ' ts. A fel-�3ut er- Pddes 2nd �� d��.shinPton Grand Island. Itebr.68801
<br /> EMBA ER—SIGNAi E/j� SENSE'NO.� REGISTRAR—SiGNA�URE � DA7E R/E�/,Fp�'FD�/�r j�.O C��i7�EG�STRA� / /�/
<br /> ? ���L"��J'_€=.W.-�b�.(., / � tAa �L t� ����GY"L�t 1�1 � S,//�A ✓.!�// r /
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<br /> �_WHrEN.`�THIS �(;�OPY'= CARRIES. THE RAISED SEAL OF THE NEBRASKA
<br /> "S'��1T�:,D$F'ARTMENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br /> A'•TRUE> COP,�Y: OF= AN ORIGINAL RECORD ON FILE WITH THE STATE
<br /> DEp�ARTME•N�T OF HEALTH, BUREAU OF VITAL STATISTZCS , WHICH
<br /> IS :'TIi{E ;,:LEGAL.�:DEPOSITORY FOR VITAL RECORDS .
<br /> _ . ��� ����
<br /> DIRECTOR OF VITAL STATZSTICS AND ASSISTANT STATE REGISTRAR �� �/
<br /> LINCOLN, NEBRASKA Issued February 25, 1975 ,;� f
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