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' DECEASED —NAIVE MST MIDDLE LAST
<br />I. Rebert Voons Curd.ngs
<br />SEX
<br />T. au '
<br />DATE OF OEA114 t MONTH, DAY, YEAR 1
<br />,. $iptsabsr 8, 1969
<br />RAGE WINTs, NEGRO, AMMKAN INDIAN,
<br />ETC. 1 EPECIVT 1
<br />N. Whits
<br />AGE —tASt
<br />pRmCAY I YEABH l
<br />s.. 45
<br />UNDE. I YEAR
<br />04058 t DAY
<br />DATE OF BATH I MONNI, DAY.
<br />YMR 1
<br />E. NIT. 23, 1924
<br />COUNTY OF DEATH
<br />T.. Hall
<br />MOS.
<br />Ik
<br />DAYS
<br />NOURE
<br />Tot. Si.
<br />MN.
<br />CITY. TOWN, OR LOCATION OF DEATH
<br />A Or
<br />(Wand I
<br />STATE Of RIRIN I N Nov tot U.S.A., NAME
<br />COIGNE?!
<br />1. Y
<br />mama e'urna
<br />m
<br />I PPECOS VII W No 1
<br />ii. HOP
<br />AL OR OTHER INSTITUTION—N tor Not IN MN, awe GMT AND NUMBER 1
<br />�, �,�
<br />N. Junction of N.J.... ills #281 and . d 2.
<br />CITIZEN OF WHAT COUNTRY
<br />P. INS
<br />MARRIED, NEVER MARRIED,
<br />WIDOWED, DIVORCED t EMCIfY 1
<br />11. �ed
<br />N SPOUSE to watt. owe MAIDEN NAM! 1
<br />( ¢
<br />11. Dorothy Louise (Iroege ,)
<br />SOCIAL SECURITY NUMBER
<br />=�`�
<br />T. 56�7�
<br />USUAL OCCUPATION lave KIND or Wpm DONE DURING MOST Or
<br />NOISING LIPS, EVEN If RITMO 1
<br />13a.
<br />KIND OF BUSINESS OR INDUSTRY
<br />fS. laming
<br />RESIDENCE- -STATE
<br />ia. .b sa
<br />COUNTY
<br />INN Hall
<br />CRY, TOWN, OR LOCATION
<br />14e. .
<br />swam co twins
<br />I
<br />14. YES OS NO1
<br />STREET AND NUMBER
<br />NT IN
<br />INK
<br />a
<br />N
<br />s
<br />■
<br />ATHER—
<br />SEP 0 8 2014
<br />LINCOLN, NEBRASKA
<br />?Towne
<br />INFORMANT —NAME — REIATIONSNN
<br />Na Mrs. Dorothy Cumings
<br />( PART I
<br />N
<br />2
<br />CONDITIONa If ANT,
<br />WINCN GAIN aim to
<br />IMMEDIATE CAUSE INN,
<br />STATING the UNDER-
<br />LYING CAUSE LAST
<br />PART N. OMM
<br />TO CAUSE GIVEN IN K.)
<br />DEATH WAS CAUSED
<br />i
<br />Wits
<br />III edeatrin -car accidept
<br />DUE TO, OR AS • CONSEQUENCE Of:
<br />t Hemorrhage
<br />{q
<br />CEm1PICATION MONTH DAY YEAS ' MONIN DAY YEAR
<br />PMY$ICIAN: TO
<br />I ATTENDED THE
<br />N.. DECEASED Noe 111.
<br />CERTIFICATION — MEDICAL EXAMINER OR CORONER: ON THE wars or at
<br />SRAMINATION Of INS EON AND /OR DEN NEYESTIGATION, IN NV OPINION,
<br />MAIN OCCURNO ON IDS DAZE AND DIN TO INS CAUSE'U STATED.
<br />9 -11 -69
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE O171G110) ' 4E'CORD ON
<br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES-4/77 R ECQRDS
<br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />r '
<br />DATE OF ISSUANCE 201407320
<br />'
<br />ASSIS DOPER
<br />ASSISTANT "STATE REGISTRAR
<br />DEPARTMENT OF hIEALTH AND
<br />i4UMMN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />Bureau of vow Statistics r
<br />tA.t MOTHER — MAIDEN NAME
<br />IN
<br />If.
<br />MAKG ADDRESS
<br />!ENTER ONLY ONE CAU
<br />CONDITIONS: COMMON COMMUTING TO DEATH BUT NOT RELATED
<br />IA. BR #1, Cairo, Itabraska
<br />NIT.
<br />NOW Of DEATH
<br />PER UNE Rain (4 (5)
<br />PART DI. IF FINALE, WAS THIN A
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />YES CI NO
<br />AND IAST SAW NW /HER ALwe ON
<br />MONTH DAY LEAS
<br />SIGNATURE a U • NS NO. ; REGISTRAR —
<br />'6'9' 10535
<br />CERTIFICATE OF DEATHd
<br />mom Mae tAS
<br />ism* / Johnson
<br />SMUT on 1.1.5. NO., CITY OR TOWN, SLATE, III
<br />TIER
<br />AND
<br />kn
<br />1 Da /DID NOT Yew THE
<br />SOW AM DEATN.
<br />Not DECEDENT WAS NONOUNCED DEAD
<br />AUTOPSY
<br />1 GS estHO)
<br />NO.
<br />STAG ENE NUMBER
<br />ETC.
<br />MPROKIMATB INRAA1
<br />USIWEEFI ONSET AND REAM
<br />diate
<br />IF YES wage riNOINGI Cow
<br />MM a
<br />e N DETISMINIT$O CAUSE
<br />ACCIDENT. SENCIDE, HOMICIDE. t MONTH. DAY, YEAR l HO INJURY. OCCURRED I ENTEM NATUI S Of INJURY IN PART I of mat II, ITEM II)
<br />OR UNOE1ERMRNED I Waft
<br />N..auto accident :lc 9/8/69 1w. 9: ec�e� tr an �
<br />INJURY AT WORK PLACE INJURY AT HOME, IA5M, smut, moor,. moor,. ON A «. 7Y... ,, Auto Accident
<br />i
<br />Ma" 'TS O. NOT OINKS NOG., ETC. I EMIGT I
<br />LOCATION 1 STOW IEEE R.T.D. NO., CnY M TOWN, STATE I
<br />I& no slr. State Highway m Rt. #2 interseaction #281
<br />DEATH OCCURRED AT THE puke, ON me
<br />moue) DALE, AND, TO INS MR
<br />Of MY KNOWLEDGE, DUI
<br />M. TO TM OWNS) STAID.
<br />9:45 p. M. 225. DALS '(19 N :00 p.
<br />- -NAAEE 'rm. oR P$Nn S 7 .. �""-' > D w mu worm, DAY, TEAR/
<br />Gs Robert 1R. Panliok, Cs. Dormer [SIGNATURE nN► r ' , - � .7-T1 , 9'-/.2- / 9.4
<br />DATE SIGNED
<br />MAILING ADDRESS — CERTIFIER STEM? 011 r.-. HO. t orwl S T A TS
<br />as 1h H fit .. a d I sl and , Hsbs+aska 6 01
<br />BUMAL, CREMATION, REMOVAL 'CEMETERY OR NAME L TION CITY OR TOW Sun TM , Burial N. Westlawn Memorial Part zit. Grand Island, Nebraska
<br />uf -" T 4OMN, DAY, YEAR I
<br />FUNERAL NOME —NAME AND ADpass i upon o r D. H nT OE wN, a tt D IP
<br />IU..Li Loa -ne raann • s 7v ' . $ `ow n o , %$zyu Island, Nebr. 68801
<br />NGISTRAR
<br />,'s, /16 f
<br />
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