|
WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND >f0VAW SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL 4!00 FlL WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISves u'G-�' o WHI wls
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _
<br />DATE OF ISSUANCE��j
<br />=U 02_
<br />AF_E1RS: COOPER
<br />JUN 15 2000 200005170 ASSIUANL STATE REGISTIiA
<br />LINCOLN, NEBRASKA HEALTH AND HU!{fi1NlSERV1€f ;SYSTEIf!
<br />STATE OF NEBRASKA - DEPARTMENT Or HEALTH T O 10665
<br />Bureau of Vital Statistics F_ _)
<br />CERTIFICATE OF DEATH 6 1 D STATE flu NUm-t
<br />DECEASED —NAME rust nowt LAST
<br />SEX
<br />M
<br />Robert William Graf
<br />D
<br />Sept. 24, 1 70
<br />1.
<br />I.
<br />S
<br />RACE wN111, NRGNO, 4mtR1CAN INWASI
<br />(d
<br />u""ll i FEAR -
<br />uNDtt T DAY
<br />S
<br />COUNTY Of DEATH
<br />G..�t.
<br />D..t
<br />1 .� rte.
<br />eK. 'tt�`ite
<br />=3
<br />far. 13, 1947
<br />1,41 Hall
<br />n
<br />n
<br />=
<br />k
<br />o
<br />o m
<br />iNSLD! em LIMITS
<br />HOSPITAL OR OTHER INSTITUTION —NAME (" NOT I" Elliott, Give STREET AND NUMttt 1
<br />2 mi. S�l mi ii Doniphan
<br />specify Yes ON NO
<br />We no
<br />2 mi. S. 1K mi, 9. Doniphan, Ile.
<br />T+.
<br />,,
<br />STATE OF MITI t IF Nor IN u.s.A_. NAmt
<br />CITIZEN OF WHAT M)NTRT
<br />MARRIED, NEVER MARRIED,
<br />SURVIVING SPOUSE I of Wirt, GIVE NAM. NAME I
<br />Nebraska `D`"e1f'1
<br />USA
<br />„�'iarriDnfo ce D 1Sr"'"I
<br />Eowden
<br />B
<br />,
<br />,
<br />SOCIAL SECURITY NUMBER
<br />USUAL OCCUPATION Tom tIND OF wota Dow ounNO most OF
<br />KMID OF BUSINESS OR INDUSTRY
<br />64 -8029
<br />WOIREING LIFE, RIPEN H -TIt1D )
<br />Farming
<br />M
<br />12..508-
<br />M.
<br />17�. --
<br />CD CIO)
<br />COUNTY
<br />CRY, TOWN, OR LOCATION
<br />I"sMf Cm Lrns
<br />STREET AND NUMBER
<br />Nebr
<br />114b Hall
<br />T)on:iphan
<br />)YY ... _ NOI
<br />no
<br />RR
<br />.
<br />Ill.
<br />14,
<br />►w
<br />FATHER —NAME FIRS Auowt LAST MOTHER—
<br />MAIDEN NAME NtST Nl D(xt LAST
<br />Lou 'rd. Gr
<br />Louis af
<br />I
<br />Verna C . Lepin
<br />s 16.
<br />IWORMANT- NAME — RELATIONSHIP
<br />MAP ING ADDRESS ISTREET 01 t. /.D, r•,^,., C:Tr CA TC , STATE, lit)
<br />Prs. Rebecca Graf wife
<br />Rural Route Doniphan, Ne. 68832
<br />M.
<br />,n.
<br />PART 1. DEATH WAS CAUSED BY: (ENTER ONLY ONE CAUSE PER ONE FOR (DI. (b). AND (c))
<br />RIMA 1
<br />SfTWetN ONSET AND DRAM
<br />1e. "1mEDtA UUSI
<br />�� (D) Traumatic Shock immediate
<br />, .5 N
<br />,...TI'�
<br />OND/TIONS, IF ANY, i1mediatCam.
<br />W"ICN OAVI RISE t0 fb) electrocution
<br />- I10011D1ATE CAUSE " N 101, pUE i0, W A! A CONSl01FRNC! OFD
<br />STATING T 1 UOtt•
<br />LYING CAU- LAST -
<br />PART U. OTHER SIGNIFICANT CONDITIONS, CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELAT90 PART IIl, REF FE:sl :, WAS Trttl A— �_ Wait FINDINGS CoN-
<br />TO CAUSE OMEN IN PART T s) PREGNANCY IN Tilt PAST 7 AEoNTHsT I TES D• NOI W DtAT"N WTt RMININO CAUSE
<br />Yes ❑ NO O 19, no IN.
<br />ACCIDENT, SUICIDE. HOMICIDE (MONTH, DAY, TRAIT 1
<br />HOUR
<br />HOW INJURY OCCURRED I ENTER NATLF- Of IN,utY IN PART 1 OR FART IRE, ITEM It )
<br />OR � accide ttFYl :,.. 9 24 70
<br />m.11:15
<br />µ. TN contact with wire from electric um�
<br />INJURY AT WCRtX
<br />PLACE OF INJURY At Howl, FAw, uteri, FAcTORV,
<br />1 -�,
<br />I�
<br />�
<br />n c>✓
<br />o :q
<br />CERTIFICATION— NGNTM DAY n&I I NON!" BM Ye At
<br />AND LAST SAW Hw /"1t &LIVE ON � 1 Oro /DID NOT zW 111e
<br />ORE ATN OCCURRED AT I"t PLACE, ON TEN
<br />CD
<br />AIONT" Dar !LAS LOO. ARM DeAM.
<br />IFg1-1 DAB, AND, To tM -11
<br />TIRE
<br />1211.
<br />or ry tNowuDw, DUE
<br />tlt.11:15 Mt CAUMIS) STATID.
<br />I DRC1A- OD/ROr )118.
<br />fill.
<br />,410
<br />CERTIFICATION— MEDICAL ExAMM4R OR e- OlEOEV'cir: ON file Ysls or TER -Out OF DRAIN Tilt V1 101NT WAS PRONOUNCED DEAD
<br />YN DAY YEAR "out
<br />"`
<br />eal.."EAf1oN a TFFe tow ANO /a THE INIP1v`•'SAIIO«, IN MY OPINION,
<br />DeAM OCCU113" ON wR DATE AND DUE TO NNE CAb:101 STATED. �, 24
<br />».. M. rn. 12, 00. noon
<br />CERTIFIER —NAME /TIP/ OR pt;Z) - A DeGttt ON Till! A S D ilAc DAT, r1Atl
<br />1b. t RY CO. TT Ii. 10 1
<br />a
<br />MAILING ADDRESS — CERTIFIER uttu ON I.F.D. cr— � �N STATE ZIP
<br />%r d
<br />ru. Box 92 Isl nd Nebra§ka b8801
<br />IURIAL, CREMATION. REMOVAL
<br />EA CTERY OR CREEM.ATORY —NAW LOCATION CITY OIL low STATE
<br />I SFlCIIY 1
<br />Cedar View Cemetery i2k Doniphan. ?,Iebr.
<br />1w. Burial
<br />K►.
<br />FUNERAL HOME —NAME AND ADDRESS : I STSttT 01 t.i.0. NO.. CITY 01 TOWN, SLATE, 11P I
<br />N 68801
<br />ATE tNONr ", DAY, YEAR)
<br />ise. Anfel Bullcr GeddeF! -2nd `IA s h i n g n • (; and T s land e
<br />SIGF*rU a E EJ
<br />itfcvrT-"i.w— SilsNAf � DATER .Y _ Al �oIITRAt
<br />o
<br />CA
<br />o
<br />W
<br />_5"�jl�3
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND >f0VAW SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL 4!00 FlL WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISves u'G-�' o WHI wls
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _
<br />DATE OF ISSUANCE��j
<br />=U 02_
<br />AF_E1RS: COOPER
<br />JUN 15 2000 200005170 ASSIUANL STATE REGISTIiA
<br />LINCOLN, NEBRASKA HEALTH AND HU!{fi1NlSERV1€f ;SYSTEIf!
<br />STATE OF NEBRASKA - DEPARTMENT Or HEALTH T O 10665
<br />Bureau of Vital Statistics F_ _)
<br />CERTIFICATE OF DEATH 6 1 D STATE flu NUm-t
<br />DECEASED —NAME rust nowt LAST
<br />SEX
<br />DATE OF DEATH 1 Nor. �, DAY, r,A. 1
<br />Robert William Graf
<br />m
<br />Sept. 24, 1 70
<br />1.
<br />I.
<br />S
<br />RACE wN111, NRGNO, 4mtR1CAN INWASI
<br />AGE —LAst-
<br />u""ll i FEAR -
<br />uNDtt T DAY
<br />DATE Of BIRTH 1 401 0". DAY,
<br />COUNTY Of DEATH
<br />G..�t.
<br />D..t
<br />1 .� rte.
<br />eK. 'tt�`ite
<br />tItTND. , tA.t)
<br />far. 13, 1947
<br />1,41 Hall
<br />t:
<br />St
<br />ST
<br />k
<br />CRY, TOWN, OR LOCATION OF DEATH
<br />iNSLD! em LIMITS
<br />HOSPITAL OR OTHER INSTITUTION —NAME (" NOT I" Elliott, Give STREET AND NUMttt 1
<br />2 mi. S�l mi ii Doniphan
<br />specify Yes ON NO
<br />We no
<br />2 mi. S. 1K mi, 9. Doniphan, Ile.
<br />T+.
<br />,,
<br />STATE OF MITI t IF Nor IN u.s.A_. NAmt
<br />CITIZEN OF WHAT M)NTRT
<br />MARRIED, NEVER MARRIED,
<br />SURVIVING SPOUSE I of Wirt, GIVE NAM. NAME I
<br />Nebraska `D`"e1f'1
<br />USA
<br />„�'iarriDnfo ce D 1Sr"'"I
<br />Eowden
<br />B
<br />,
<br />,
<br />SOCIAL SECURITY NUMBER
<br />USUAL OCCUPATION Tom tIND OF wota Dow ounNO most OF
<br />KMID OF BUSINESS OR INDUSTRY
<br />64 -8029
<br />WOIREING LIFE, RIPEN H -TIt1D )
<br />Farming
<br />Agriculture
<br />12..508-
<br />M.
<br />17�. --
<br />RESIDENCE —STATE
<br />COUNTY
<br />CRY, TOWN, OR LOCATION
<br />I"sMf Cm Lrns
<br />STREET AND NUMBER
<br />Nebr
<br />114b Hall
<br />T)on:iphan
<br />)YY ... _ NOI
<br />no
<br />RR
<br />.
<br />Ill.
<br />14,
<br />►w
<br />FATHER —NAME FIRS Auowt LAST MOTHER—
<br />MAIDEN NAME NtST Nl D(xt LAST
<br />Lou 'rd. Gr
<br />Louis af
<br />I
<br />Verna C . Lepin
<br />s 16.
<br />IWORMANT- NAME — RELATIONSHIP
<br />MAP ING ADDRESS ISTREET 01 t. /.D, r•,^,., C:Tr CA TC , STATE, lit)
<br />Prs. Rebecca Graf wife
<br />Rural Route Doniphan, Ne. 68832
<br />M.
<br />,n.
<br />PART 1. DEATH WAS CAUSED BY: (ENTER ONLY ONE CAUSE PER ONE FOR (DI. (b). AND (c))
<br />RIMA 1
<br />SfTWetN ONSET AND DRAM
<br />1e. "1mEDtA UUSI
<br />�� (D) Traumatic Shock immediate
<br />, .5 N
<br />,...TI'�
<br />OND/TIONS, IF ANY, i1mediatCam.
<br />W"ICN OAVI RISE t0 fb) electrocution
<br />- I10011D1ATE CAUSE " N 101, pUE i0, W A! A CONSl01FRNC! OFD
<br />STATING T 1 UOtt•
<br />LYING CAU- LAST -
<br />PART U. OTHER SIGNIFICANT CONDITIONS, CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELAT90 PART IIl, REF FE:sl :, WAS Trttl A— �_ Wait FINDINGS CoN-
<br />TO CAUSE OMEN IN PART T s) PREGNANCY IN Tilt PAST 7 AEoNTHsT I TES D• NOI W DtAT"N WTt RMININO CAUSE
<br />Yes ❑ NO O 19, no IN.
<br />ACCIDENT, SUICIDE. HOMICIDE (MONTH, DAY, TRAIT 1
<br />HOUR
<br />HOW INJURY OCCURRED I ENTER NATLF- Of IN,utY IN PART 1 OR FART IRE, ITEM It )
<br />OR � accide ttFYl :,.. 9 24 70
<br />m.11:15
<br />µ. TN contact with wire from electric um�
<br />INJURY AT WCRtX
<br />PLACE OF INJURY At Howl, FAw, uteri, FAcTORV,
<br />LOCATION I sttIlI W t.r.o. NO., Cm W TOWN, sun )
<br />I SPlCIPT TES Ot NO 1
<br />oF►K1 ft"" 11c. I wcm)
<br />-
<br />to 2 mi. South 11 miles west of Doni han
<br />,w tIl
<br />CERTIFICATION— NGNTM DAY n&I I NON!" BM Ye At
<br />AND LAST SAW Hw /"1t &LIVE ON � 1 Oro /DID NOT zW 111e
<br />ORE ATN OCCURRED AT I"t PLACE, ON TEN
<br />►NYBICIANI TO
<br />AIONT" Dar !LAS LOO. ARM DeAM.
<br />IFg1-1 DAB, AND, To tM -11
<br />TIRE
<br />1211.
<br />or ry tNowuDw, DUE
<br />tlt.11:15 Mt CAUMIS) STATID.
<br />I DRC1A- OD/ROr )118.
<br />fill.
<br />,410
<br />CERTIFICATION— MEDICAL ExAMM4R OR e- OlEOEV'cir: ON file Ysls or TER -Out OF DRAIN Tilt V1 101NT WAS PRONOUNCED DEAD
<br />YN DAY YEAR "out
<br />"`
<br />eal.."EAf1oN a TFFe tow ANO /a THE INIP1v`•'SAIIO«, IN MY OPINION,
<br />DeAM OCCU113" ON wR DATE AND DUE TO NNE CAb:101 STATED. �, 24
<br />».. M. rn. 12, 00. noon
<br />CERTIFIER —NAME /TIP/ OR pt;Z) - A DeGttt ON Till! A S D ilAc DAT, r1Atl
<br />1b. t RY CO. TT Ii. 10 1
<br />a
<br />MAILING ADDRESS — CERTIFIER uttu ON I.F.D. cr— � �N STATE ZIP
<br />%r d
<br />ru. Box 92 Isl nd Nebra§ka b8801
<br />IURIAL, CREMATION. REMOVAL
<br />EA CTERY OR CREEM.ATORY —NAW LOCATION CITY OIL low STATE
<br />I SFlCIIY 1
<br />Cedar View Cemetery i2k Doniphan. ?,Iebr.
<br />1w. Burial
<br />K►.
<br />FUNERAL HOME —NAME AND ADDRESS : I STSttT 01 t.i.0. NO.. CITY 01 TOWN, SLATE, 11P I
<br />N 68801
<br />ATE tNONr ", DAY, YEAR)
<br />ise. Anfel Bullcr GeddeF! -2nd `IA s h i n g n • (; and T s land e
<br />SIGF*rU a E EJ
<br />itfcvrT-"i.w— SilsNAf � DATER .Y _ Al �oIITRAt
<br />p
<br />E
<br />1
<br />i
<br />e
<br />Recorder's Memo: The North Half of the Southeast Quarter (N%SE %)
<br />of Section Fourteen (14), in Township Nine (9) North, Range Ten
<br />(10), West of the 6th P.M. in Hall County, Nebraska
<br />
|