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<br /> Lot Fifteen (15), in Block Eight (8), Boggs and Hill Addition to the City of Grand
<br /> Island, Hall County, Nebraska
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<br /> STATE OF NEBRASKA-DEPARTMENT Of HEAITH �'
<br /> � �� u� � �'�� � BUREAU OF VITAL STATISTICS
<br /> CERTIFICATE OF DEATH 6 , - ,,
<br /> DECEDENT-NAME FIRST MIDDIE UST SEX DATE Of DEATH(Mo.,Doy,Yr.)
<br /> , Joseph �;Joodrota riridersori � T�I�zle ,�ece�:iuer 2, ly£�l
<br /> RACE-(�.g.,Whi��, Block,Am�rican ORIGIN/DESCENT(�.g.,Italian,Muimn, AGE-�o��linhdoy UNDER 1 YEAR UNDER 1 DAY DATEOFBIRTM�Mo.,Day,Yr.)
<br /> Indian,�kJ(Sp�cifyJ Gsrmon,Nc.)(Spacily) �� (Yn.) MOS. DAYS HOURS�MINS.
<br /> �. llhite S. Swedish � ,a, 65 ,b � ;�lov. lj, 1916
<br /> CITY AND STATF Of BIRTM(1!no/in U.S.A., C�TIZEN OF WMAT COUNTRY MARRIED,NEVER MARRIEO, NAME OF SPOUSE(1/ri/�,gir�moid�n nom�)
<br /> nam�counlr 1 � WIDOWED,DIVORCED�Speci/y)
<br /> e. I�ioii�rose, S. D. y) `� 9. USi� ,o. il�.rried „�velyn i;able �snderson
<br /> SOCIAL SECURITY NUMBER USUAI OCCUPATION/Gir�kind of wor4 don�during moc� KIND Of BUSINESS OR�NDUSTRY COUNTY OF DEATM
<br /> o/working lila,ar�n ilrslir�d) :�
<br /> ,z. 50 —07-7�22 ,30_ I,aborer ,+.�y t ,36Construction „o. Hall
<br /> CITY,TOWN OR IOUTION Oi DEATM INSIDE CITY lIM1T5 HOSVITAI OR OTMER INSTITUTION-Noma (���of in eifher, If MOSY.OR INSi.Indimr�DOA,
<br /> (Speci/y Yes or No) gir�t�rpal ond number) Ovrpali�nl/Emv.lm.Inpah�nl(SpKilr)
<br /> ,.b. Grand Island ,k. Yes ,.d. �t. r'rwncis 1led. Center ,.�. Inl�atient
<br /> RESIDENCE-SiATE COUNTY CITY,TOWN OR IOCATION STREETAND NUMBER INSIDE CITY IIMITS
<br /> (Sp�ci/y���or No)
<br /> ,s�i�ebrauka ,sb. Hall ,s�.Grana lsla.nd ,sd�9U8 1!. llth �t. ,Se, es
<br /> fATHER-NAME fIRST MIDDLE UST MOTHER-MAIDEN NAME FIRST MIDDLE LAST
<br /> 16. ��Jillie.�m E�nd�rson ,, Catrierine Sullivan
<br /> WKS c7ECiI.SED fYFR IN J.S. AWMEC fORCfS? �NFORM�►NT-NdME-RELA110NSHIP-MAIUNG ADORE55 (STRFEi OI�R�Q.�f�,,���T�if�Q11�TO���I�i1
<br /> (Ya�.no,or unY) (11 re� give..or ond dote�ol� .�e)
<br /> , . . ; - c. ,vl�ir.�. 1�ve1 �',�zcierson-ti�life-lyU£3 lJ. llth ;:it. , Gra.nd�
<br /> BURIAI,Cremation,Removal DATE CEMETERY OR CREMATORY-NAME IOCATION CITY ON TOWN $TATE
<br /> � a - ob . 5 1 �il s�Westia�m 1-ier:lori:�l rark soa. Grand Islarid Ne.
<br /> MO ER-SIGN iURE IC O. ,l� FUNERAI MOME-NAME ANO ADDRESS (STRFET OR R.fD.NO.,G�TV OR tOM�N,STATE,ZIP)
<br /> z , G ��7 zz.Livin -�ston—Sonderr����?ti�F'uner��l �io ,e Gr�a.nu Islaiic! 1Ve.
<br /> DATE O D M( o.,Day,Yr.) DATE SIGNED(Mo.Day,Yr.) MOUR OF DEATM
<br /> i.
<br /> � �'i
<br /> �< u
<br /> yv 2Ja. �-°` 2Ia. 216. /�
<br /> .y DA SIGNED(Mo.,•OoylCY,r� ' MOUR OF DEATH _=C PRONOUNCEO DEAD PRONOUNCED DEAD(Hour1
<br /> ae- oN�o (Mo.,Day.Yr.)
<br /> �� 4�6. 7 D0C. ]9� - ���. 5�-�"� � P M ���`..� 21c. 21d M
<br /> �� To rh�bo�of my Ynorbdqyd�anc �u P��h�timd,dab anQ plac�and du�lo th� s Q O On th�ba�i�ol�aamina�ion and/or inw.�igallon,in rnr op���on d�a�h u<urr�d al
<br /> o= co��N�)��a��d. � r� 1 ��v �h�tim�,da�e and plac�and dw m tM waw14��a��d.
<br /> �t o
<br /> 2 J d.fSl yno��..and ffrl•) -{ 2�a.(Sly�a�ur•and i�N�)�
<br /> NAME AND ADDRE55 OF CERT IE - � YSICIAN, E V YSI IA O Y ATTORNEY)(Type or Vrinl)
<br /> ss. G. D.
<br /> Fr�.ncis I�T. 1). lU tidest l.oeni r St. Urai�d l;,land, iie.
<br /> REGISTRAR _ DATE REGEIVED BY REGISTRAR(Mo.,Day,Y..)
<br /> Tba.(Slp�aror�)��/`� 'v -iLl�� ���'��-�C'f"I,..��. 26���G������ ' / ��
<br /> 77. IMMEDIATE CAUSE (EMER ONLY ONE CAUSE PER LINE fOR(01.(bJ,AND(c)) � ���•ral b.+....�on���and dw�h
<br /> PART �
<br /> ; ,Massive pulmonary embolism � 45 min.
<br /> � DUE TO,OR A$A CONSEOUENCE OF: � I��•nal b•w•.n on���a�d dwth
<br /> cb>Fracture pelvic bones with ruptured urethra and fracture mandible� 8 days
<br /> DUE TO,OR AS A CONSEQUENCE OF: � I17dllSLT131 accident;.�����'�b�tw��n o����ond d�atA
<br /> (d -- �
<br /> PART �TMER SIGNIfICANi CONDITIONS-Co�di�ion�contrib��inp�o dw�h bur not r�lo��d PART III.IF fEMALE,WAS THENE A AU70PST wA5 CASE REFERRED i0 MEDICAI
<br /> PREGNANCY IN TME FAST]MONTH57 (Sp�ai/r/'u or No) EXAMINEN O�CORONEN
<br /> II (Sp�cilr Yn or No)
<br /> I�one w.❑ No ❑ se. ye s zv. No
<br /> ACCIOENT,SUICIDE,MOAVCIDE,UNDET., DATE OF INIURY(Mo.,Dar,Yr.) MOUII Of IILURY DESCR�I6�TE MOW IN1UR1'OCCUNNED
<br /> ORiENDINGINVESTIGATION.(Sp�ulr) Wa$ a��_ work when load Of sheetrock
<br /> aoa.Accident �ob. 24 Nov. 81 3�Early pM 30d.
<br /> INIURY Ai WORK ►UCE Of INIURY-A�hom�,larm,�tr��r,lactory, IOCATION STREET OR RF-0.No. CIT1'OR TOWN STATE
<br /> (Sp�cilr Yu or Ne) olfk�buildinp.�tc.fSp�cil�l
<br /> sa. 3or. ao . '
<br /> w � / �� ■ ___-
<br /> ���.
<br /> WH�N. THIS CCL��X (;ARRIES THE RAISED SEAL OF THE NEBRASKA
<br /> ST��TE DEP�c'�£M;�NT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br /> A TRUE COPY 0�'_AN ORIGINAL RECORD ON FILE WITH THE STATE
<br /> DEPARTMENT OF' ;HEALTH, BUREAU OF VITAL STATISTICS , WHICH
<br /> IS T.H'E LEGAL,. DEPOSITORY FOR VITAL RECORDS .
<br /> . .
<br /> �/L�.d.Q. �t.t�t.�J
<br /> DIRECTOR OF VITAL STATISTICS AND ASSISTANT ST9TE REGISTRAR
<br /> LINCOLN, NEBRASKA Issued December 15, 1981 _ '
<br />
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