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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AIANNNAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGML -RECORDFILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL SM - W34M/CH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE 2' 0 0 0 0 2 19 5 = = = BEY . QD1 PER <br />APR 71999 �smwsrATE MTRAR <br />LINCOLN, NEBRASKA HEALTHANOWUNAN SE�APSTEM <br />C'.) v' <br />o <br />M CA <br />-- <br />N <br />C Q <br />n U) <br />a STATE Nebraska b, COUNTY allb`tere admisdon). <br />r <br />—+ m <br />M <br />c' - <br />N <br />-[ <br />rural <br />o <br />O M <br />m <br />`v <br />O <br />_ <br />-n <br />O <br />ADD <br />= m <br />o <br />N <br />N <br />C M <br />r 70 <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AIANNNAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGML -RECORDFILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL SM - W34M/CH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE 2' 0 0 0 0 2 19 5 = = = BEY . QD1 PER <br />APR 71999 �smwsrATE MTRAR <br />LINCOLN, NEBRASKA HEALTHANOWUNAN SE�APSTEM <br />C'.) v' <br />o <br />M <br />o —i <br />- <br />N <br />r •. <br />Z <br />a STATE Nebraska b, COUNTY allb`tere admisdon). <br />—+ m <br />O <br />STAY t <br />-[ <br />rural <br />TOWN S <br />C �t <br />O <br />M <br />CCn <br />-n <br />O <br />ADD <br />= m <br />o <br />. C <br />n CO <br />C M <br />r 70 <br />N <br />S. SEX L COLOR or RA-14 T. MARRIED. NEVER MARRIED a. DATE OF BIRTH S <br />r n <br />Under I Yr.11f n <br />nder 24 Hra. <br />u' <br />►-� <br />co <br />10a. USUAL OCCUPATION (Give kind of work) lob. KIND OF BUSINESSI 1 <br />=3 <br />n <br />CO <br />. <br />to <br />cn <br />o <br />CO <br />ietrich j a e <br />Pxs -'ran s arv. 4-{a TSKAIKA, vr- rt n6A <br />FEDERA s A <br />PUBLIC HEALTH SERVICE Bureau of Vital Statistics <br />BIRTH NO. 126 CERTIFICATE OF DEATH STATE FILE NO. <br />1. PLACE QF DEATH L <br />L USUAL RBSIDYNCZ (Where deeeased lived. If InaUtudont residence <br />a. COUNTY Adams a <br />a STATE Nebraska b, COUNTY allb`tere admisdon). <br />L CITY (If outside corporate limits. write Rural) G <br />G L E N G T H OF e <br />e. CITY (If outside cotporate limits,. write RURAL) <br />STAY t <br />this K T <br />rural <br />TOWN S <br />TOWN r <br />d. FULL NAME OF (If not in hospital or institution, give street address d <br />d. STRRET (If rural. give location) <br />O SPITA N Mary Lr✓.czning or location) A <br />ADD <br />. C <br />4. DOAFTE (Month) (Day) (Year) <br />C M <br />i (Type or Priat) D <br />DEATH <br />S. SEX L COLOR or RA-14 T. MARRIED. NEVER MARRIED a. DATE OF BIRTH S <br />S. Age (In TrLjIf U <br />Under I Yr.11f n <br />nder 24 Hra. <br />IWIDOWED. D <br />10a. USUAL OCCUPATION (Give kind of work) lob. KIND OF BUSINESSI 1 <br />11. BIRTH- (City, town or county) (Statel 12. CITIZEN OF WHAT <br />done during most of working life. even It retired)I f <br />PLACE or for country) COUNTRYT <br />f' O <br />2. FATHER'S NAME 1 <br />14a. MOTHER'S MAIDEN NAMB 1 <br />14L NAME OF HUSBAND OR WIFE <br />ietrich j a e <br />edf 1 <br />m WP [*-R . <br />.. i <br />„„� no l <br />la. CAUSE OF DEATH MEDICAL CERTIFICATION Interval Between <br />Enter only one cause per I. DISEASE OR CONDITION Onset and Death <br />line for (a). (b), and (c) D <br />DIRECTLY LEADING TO DEATH* ' <br />(a) <br />*This don net mean the ANTECEDENT CAUSES ` L�. 1 <br />1c�(?�Yt -�_ _ ✓ <br />/�� <br />