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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HU_MANSERVICES ' SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL ,REGOM -QMIE40►TH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT ►STIGN� II,: I*WWIS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF I U _ -U AlR 1�t�� ASS /$'AW STATE AEi;I$TR1 12 LINCOLN, NEBRASKA HEALTH AND HiAiA11f,�EltVICES 3 VS7`Ell€ 20000912'd _a Pxs- vea�vS) it>ay. 4-4s STATE OF NEBRASKA WSI-RA S MI AGENCY DEPARTMENT OF EO ALTH PUBLIC HEALTH SERVICE Bureau Of Vital Statistics BIRTH No. 126 CERTIFICATE OF DEATH STATE Flrza rro_ _1. PLACE QF DEATH 2. USUAL RESIDENCE (Where deceased lived. If institution: residence a. COUNTY Adams 3"!1 a. STATE b. COUNTY before admission). Nebraska Hall b. (If outside corporate limits, write Rural) c. CITY (If outside corporate limits,: writes RURAL) ,CO Y thls �� rural TOWN N b o TOWN --Hastings, d. FULL NAME OF (If not in hospital or institution, give street address d. STRRET (If rural. dive, location) HOSPITAL OR or location) Mary Lanning ADb I INSTITUTION mi- S - E- of Grand cl and DECEASED a (First),. b. (Middle) a (Lost) - 4. A (Month) (Day) (Year) ( (Type or Print) ntear Harry Ni Pdf P1 t nEATH Mar- 1 _ - 1949 6. SIM Male ' 6. COLOR or RACE I w i-- 7. MARRIED NEVER MARRi&D II WIDOWER. DIVORCED (Specify) I married S. DATE OF BIRTH 9. Age (In yrs If Under 1 Yr. 4wt birthday) Mos. Days 112- 14/191 -0_ I If Under 24 Hrs. Flours Min. I I 10a. USUAL OCCUPATION (Give kiwi of work 10b. KIND OF BUSINESS -438 11. BIRTH- (City, .town or county) (State n. CITIZEN of WHAT done during most of working life, even if retired) OR INDUSTRY PLACE or for country) ( COUNTRY? �- k . FATHER'S NAME 1426. MOTHER'S MAIDEN NAME 114b. NAME OF HUSBAND OR WIFE ietrich ie l IF P I n e edf 1 . WAS DECEASED EVER IN U. S. ARMED FORCE'S? 26. SOCIAL SECURITY 17. INFORMANT'S NAME or Signature do Address (Yes, no. or unknown) (if yes. give war or dates of service )I NO. 1 Mrs. n�, none Mrs. Bernice Niedfelt -910 _ 16. CAUSE OF DEATH MEDICAL CERTIFICATION Interval Between Enter only one cause line for (s), (b), and (c) I. DISEASE OR a . . Onset and Death DIRECTLY LEADING TO DEATH ADDING TO rThis does not mesa the ANTECEDENT CAUSES mode of 'd'sing, much as DUE TO (b)eLf.�Cn_.. heart failure, asthenia. Morbid conditions. If any, giving etc. It means the rho to the above cause (s) stating ` ease, •ln) which or comp the underlying eauw last. DUE TO (c)_. _. .. . Lion which caused death. �" 11. OTHER SIGNIFICANT CONDITIONS Conditions contributing, to the death but not related to the disease or condition causing death. 19a. DATE OF OPERA- 19b. MAJOR FINDINGS OF OPERATION 20. AUTOPSY I TION 1 Yes V No CCIDENT (Specify) PLACE OF INJURY (eg., in or about 21e. (CITY OR TOWN) (COUNTY) (STATE) qa. 121b. UICIDE home, farm, factory, street. office bkig., eta) (If rural area. write RURAL) OMICIDE 21d. TIME (Mouth) (Day) (Year) (Hour) . 210. INJURY OCCURRED While at Work ❑ 211. HOW DID INJURY OCCUR? OF INJURY m. . 1 Not While at Work Uq 22.1 hereby certify that I attended the deceased from ..�. ,,d 199. to... ..I. -. -; 9 .., that I last sate de- ceased alive on.It.- .161 - 19.4.01, and that death occu d a .g......P. m., from the. causes and on the date stated above._ 23a. SI TURZQ (Demme orAw 23b. D ! 23c. DATE SIGNED Zia. B . IAL. C R E M A -1 24b. DATE 24c. NAME OF CEMETER CREMATOR 24d. LOCATION (City, town, or county) ( ) TION, REMOVAL (S.°ecifyil I D LOCAL I 'S SIGNAT r� 2S. FUNERAL DIRECTOR'S SIGNA'T'URE ADDRESS Rio I CIL-