|
_.. � �
<br /> ,. .
<br /> � �. . ._. . ` r- _ .;: -1
<br /> .. .
<br /> • STATE OF IVEBRASKA—DEPARTMEMi'OF IIEALTf1 � . "
<br /> 7$�1.o 0 o A C� Burrou of Vilol Sculis�ic� r � � . . . ��
<br /> `��� CERTIFIGATE OF DEATH,���„� • �
<br /> . ,
<br /> OEQASED—NAME . . rr�� r�ew� ��sr yE� DAiE Of DEATM��o� , , ���� � �
<br /> � John F'rederick West o Male � ku�ust 6 ,l,pD•�7
<br /> RACE wwrr�.w�aq,�r���c�r iwo�.w, AGE—i�a� • DATE OF lIRTM�.o«n., p l�r
<br /> ut. �artCpr� ��n ��roi.' wri �wne��o.♦ •�. COUNT�O!DEATM . . .
<br /> � White s� 0.6��.. M .. s.�,.. »�. �Apr. 29� 1911 „ Hall
<br /> �CT',TOWN,Ot IOCATION pf p(ATM � iee n�ur� �/OS�I7Al pR OlNfN INSTIiUTpN—NwMF iir.p�ir���n��,�iv�y � � �
<br /> HI<�r���3 O�'no ��ter�rW w � . .
<br /> n Grand =slattd ,, Yes ,. Lutheran i�morial �ospital •
<br /> STATE Of�I�iX���war iw u. •„w�r<CITREN Of W�}�puNTqr /�y�RRIED,NEVER A1ApR1ED, SURVrvW('.SPOUSE�n e,Gm.u�oew«.we� -
<br /> ,c���� WIDOWEO.DNOPCE �srKin� w"
<br /> . Nebraska , IISB ,. 2i:irriec� „ �,velyn R. Kitvley
<br /> SOCIAt$ECU�ITY NUMlF� U„Al OCCUTATION�c�ve�ueoOr wp��ppM�ou��r.e rosr o [IND Of WSINESS OR INGVSTRY -- �
<br /> . � l�i�eo� '
<br /> �r. 12-0 1 ,� 12etired Car Ins ector _ „� Railro.;,ciin�
<br /> RESIDENCE—iAtf COUNiY �ITY,iOVIN,pR IOCAiION �w>�ot c�w�u��n STREEi �NO NUM�f■
<br /> �M.?Iebruska. �o Hall ��, Gsa,tld Isltsnd ��������Ye9� ��, 355 South Plum
<br /> /AIMER—NAMf r�ur ..qqt �.f� MOIHE�—wU/DENNAMf �i�a� ��oo�� . . .
<br /> �s. Geor {•lest �,. blinnie Voss
<br /> ��.WAS DECfASED EV�R IN U.S.ARMEO FORCE51 INfORMANT—NAMf—IE1A710NSH11—w��,p��a(�.AOOIIESS �I �
<br /> ; no y.O«...i»..� u�n�.ao....w ee�«w....�.d �n.a.o..,o .o.cn.o.w.,.., ` � .
<br /> ; iw �,. Mrs. Evelyn �dest-1•7i£e-355 Soutk, Plum, Grand Island,Ne.
<br /> � �'�T�� DEA7N WAS GUSED!r, �ENlEf ONIY ONE C�USE/fR(ME!OR
<br /> + 1�. . uwo�.n<.uf1 fo/,fbl.�NO f�/l M1I�.�.owaer. . . .
<br /> ' � ��� . . . .. C�11/1 � .
<br /> }
<br /> coremo«�.n w. / I � .
<br /> r ceo�v�.�>i,o ee; //
<br /> �«c� �
<br /> ei u . u o.oe.a.<o��e o.a o.. K � .
<br /> iawc<.uu ua� �
<br /> ��'
<br /> � �YT n. OiMlt SIGNI/KYII CONq1pMT.CONdT�ON3 COMf���YtINO i0 DlwiN Wf HOI�fL.�iED /A�T 111.If I[IMl[.WAS lME\!A AUTOISY IF�'f5���t I�wO�r�G1 COi+- -�.
<br /> TO.UYS[G1VlM IN��tT K�) .��� ��FGlUMCY IN�M!�AS!]MONiM51 �r� 01 O�D�� O Uut! .
<br /> ACCIDEM.5[lIC1DE.NOMICIDE. A 1 �pVy�p� �� rf3❑ Ia0❑ 11•1 I1'. f�tN o����r�«�w . .. . .
<br /> OR UNOfTERMNEG�snan� • • ��� NOW INIVRY OCCU4IED���ne��run or�..����r..�.�r�o�r.n .in��t� . . .
<br /> 7r. .� . 10Y. ]p M. 701 . . . .
<br /> IN1U�T.AT WORo nACF,pf pV/tJRY��wOW.r nl�r o���.e.w .cin o�r
<br /> 13�IC1/t��f MK�4OG..fK VN�n� •�� • �«�• IOCAiION �f O ,ft�R� . .
<br /> . � �a.' �- rw . ..
<br /> .[QIilGilp�—
<br /> � �� MYSKI�n:. �w O�� i��� rpHm o�r •e�� r�.�Yw wtr:r��:• er/o/e rOr viM tn�D(I.IM OCCU��lO • yK1.y�M� �
<br /> � lrWO IM/�'�-� �tO � 'w �O �i!�Of�M. t:w�� .
<br /> 1��. o�u.ue rw.. � t�� 7�� _,� �»o o��.i:a v"wroieeo�o�w � . � . ... .
<br /> CERTpIGTIpM—µ[OICA E](AMINEII OR C ER:or�rw����s Or rM O 7M V, (y M.�o tw�c��s��a�u�uo . . .
<br /> s�.u�a�1q�+w nN�oo��re/w�M r�v��nGuwr.�r r�orwro.., � u�or ww�w e oKrl�1 r �a�wou^.�n ouo �
<br /> �er.a oeeu��es�w nn e.n u.o ow ro c.uuni sr.reo. . . � � . . .
<br /> �CERTIHER—NAME mn p ru«n �� M.t1Y. �O b . . �.
<br /> 5 AT DATE SIGNED�+a+w,o��,nu M
<br /> :H. S. J. Ander�on iq, D, •°
<br /> � MAMING'ADORESS—CflTtl[t r o�� <in a !A. .. . . .
<br /> i "' 8�1��•fest Seaond :�t Grand�Island ��N 6880
<br /> ���A�.�C�EMATqN.R(MpVAI CFMEiE��O�CIIEMATORI'—NAME LOCATION c�n o�p•rw f . .
<br /> � 1��/
<br /> ��. � 7�1. I � 7��. I
<br /> � DA7E � i.q��ti,y � FUNERAI MOME—HAME ANO'ADOIlESS � o ,�in w ,ti�i � �
<br /> "� n.. I,ivi sto - o d r ,••�•• •� �
<br /> EM�AIMER—SICNA►URE{UClNSE NO. 188Q REGIST�A4—SICNwtURE D�te�e<e�vto���p�� ��G�31•
<br /> :ss. +� .,.,,�. ' .
<br /> �*'�f��,,�,.d' — �«. y yia�� �
<br /> �,ita�,.u�.a� ��,�,� � `r�j�f�f✓l�it �.� �j�����/y��
<br /> i4---.�._a�... a. " (it
<br /> . � WHBN?'T$�,$'�COPY CARRIES THE RAZSED SEAL OF THE NEBRASKA
<br /> , 'a,_'"' �STATE .,DE�RTMENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br /> �`+� �1`RU'E�C OF AN ORIGINAL RECORD ON FILE WZTH THE STATE
<br /> '��'�f� ,� P��Tb���OF HEALTH, BUREAU OF VITAL STATZSTICS, WHZCH
<br /> ����1}'�-'I3E`GAL DEPOSZTORY FOR VITAL •RECORDS.
<br /> . "< 4 P��E t�t' ��t'� -- l��e e�,t,,s,�,�
<br /> ; DZRECTOR OF VITAL STATISTICS AND ASSISTANP STATE REGZSTRAR
<br /> LINCOLN, NEBRASKA Issued September 29, ig77
<br /> s
<br /> ,,.:<
<br /> � �
<br /> � � � �'::
<br /> r.�;
<br /> :`' ��
<br />, .; ,
<br /> . �. .K. :
<br /> . ,�� '£`
<br />�
<br />� � �
<br /> 1
<br />
|