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STATE OF NEBRASKA- DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS 200009008
<br />CERTIFICATE OF DEATH �.
<br />DECEDENT -NAME FIRST M
<br />MIDDLE LAST S
<br />SEX D
<br />DATE OF DEATH (M.., Day, Yr.)
<br />Fred F
<br />Frick I
<br />I'Iale J
<br />Janu
<br />2. 1
<br />J
<br />RACE-(e.g_ White, Block, American O
<br />O, I
<br />Italian, Mexican, A
<br />AGE -fart Birthday U
<br />UNDER , YEAR I UNDER , DAY D
<br />DATE OF BIRTH (Mo., Day, Yr.)
<br />MOS. DAYS H
<br />HOURS , MINS.
<br />J R
<br />German, etc.) (Specify) (
<br />(Yrs.) M
<br />f 4. S
<br />S. -
<br />-r a 6
<br />6a. 6b. b
<br />bc. 7
<br />7-Qctober 2, 1. 07
<br />CITY AND STATE OF BIRTH (If not in U.S.A., C
<br />CITIZEN OF WHAT COUNTRY M
<br />MARRIED, NEVER MARRIED, I
<br />NAME OF SPOUSE (ifwif., give ..idea name)
<br />name country) W
<br />WIDOWED, DIVORCED (Specify)
<br />I N
<br />8. 9
<br />9. L� 1
<br />10. I 1
<br />SOCIAL SECURITY NUMB U
<br />USUAL OCCUPATION (Give kind of work done during most K
<br />KIND OF BUSINESS OR INDUSTRY C
<br />COUNTY OF DEATH
<br />of working life, e
<br />even if retired)
<br />- - o
<br />13a. 1
<br />13b. i .
<br />..
<br />CITY, TO N OR LO TI OF DEATH I
<br />INSIDE CITY LIMITS H
<br />HOSPITAL OR OTHER INSTITUTION - Nome (If not in either, IF H
<br />HOSP. OR INS7. Indicate DOA,
<br />Island 1
<br />(Specif Yes or No) g
<br />give street and number) O
<br />Outpatient /Eme, Rm., Inpotient (Sp«ify)
<br />14b. Grand I
<br />14c. V
<br />105 We 15th St. 14e.
<br />RESIDENCE - STATE C
<br />COUNTY C
<br />CITY, TOWN OR LOCATION S
<br />STREET AND NUMBER I
<br />INSIDE CITY LIMITS
<br />l 15..ITebraska 115b. H
<br />Hall ,
<br />Grand Island 1
<br />105 W. 15th St. 1
<br />15e °Cf ,Yeessor No)
<br />,,c. G
<br />15d. 1
<br />FATHER -NAME FIRST M
<br />MIDDLE LAST M
<br />MOTHER-MAIDEN NAME FIRST MIDDLE LAST
<br />,s. Jacob F
<br />Frick 1
<br />17, Katherine Kistler_ _
<br />' WAS DECEASED EVER IN U.S. ARMED FORCES? I
<br />_
<br />rra-
<br />IT- n r unh) (If yes, ge- - and dote, of te)
<br />I 1e. a
<br />19Ruth Frick -Wife 10 W. 1 th St. Gr;,nd Island, Ned
<br />BURIAL, Cremation, Removal D
<br />DATE C
<br />CEMETERY OR CREMATORY -NAME L
<br />LOCATION CITY OR TOWN STATE
<br />20..i3u' .. 2
<br />2Db.J . 6 1
<br />1983 2
<br />20c. ;lestlawn Menorial Park 2
<br />20d. Grand Island, lie.
<br />EMBA /, ,CE „YNO. ��yp F
<br />FUNERAL HOME -NAME AND ADDRESS (STREET OR A.F.O. NO., CITY OR TOWN, STATE, ZIP)
<br />21 ' �� D
<br />22. living st on- Sonde rmann's 05 W.,ioeniF,, Grand Island3 Ne,
<br />DATE OF ATH (Mo., Day, Yr.) D
<br />DATE S
<br />SIGNED (Mo. Day, Yr.) H
<br />HOUR OF DEATH
<br />i -
<br />zW
<br />vN 2
<br />-3 -83 �
<br />HwO 24a. 2
<br />24b. M
<br />DATE SIGNED (Mo.,, Day, Yr.) H
<br />HOUR OF DEATH =
<br />DEAD P
<br />PRONOUNCED DEAD (Hour)
<br />=C PRONOUNCED D
<br />1 -5-83 5
<br />5320 a e
<br />ehZ a (Moe, D
<br />Day, Yr.)
<br />°c T
<br />236. 2
<br />23c. M °
<br />z 24c. 2
<br />21d.
<br />To the best of my h.- Itidg., death -Yr ed ar the e
<br />ei me date o Alcddue to the '
<br />the boric of examination and /or inv.rtigation, in my opinion death «tuned at
<br />o °
<br />On t
<br />{ v
<br />a
<br />23d. (Signature and Title) 2
<br />24e. (
<br />(Sigoot -is and Title)' '
<br />--ti. vB c.UUnn At IUKNtT) ffype or Print)
<br />9
<br />�c R nhn rri W- TIaTAav_ M Tl. 79 1 L.T. 7+11 C+ No i Rpp l
<br />rREGISTRAR D E, RECEIVED BY REGISTRAR (Mo., Day, Yr.)
<br />27. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (o), (b), AND (c)) �' , Interval be-... ant., aad death
<br />PART
<br />a, Abdominal carcinomatosis ? 2 months
<br />DUE TO, OR AS A CONSEQUENCE OF: , Intervoi be-... oases and death
<br />(b)
<br />I DUE TO, OR AS A CONSEQUENCE OF: Interval b.tw ... *..,.t and death
<br />1 PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to death but not related PART III. IF FEMALE, WAS THERE A AUTOPSY wAS CASE REFERRED TO MEDICAL
<br />If PREGNANCY IN THE PAST 3 MONTHS? (Spec? /y Y.s or No) EXAMINER OR CORONER
<br />` Laennecs Cirrhosis of Liver Yes ❑ No ❑ 29. No (Sp-ify Yes or No) No
<br />29.
<br />ACCIDENT, SUICIDE, HOMICIDE, UNDET., DATE OF INJURY (Mo., Day, Yr.) HOUR OF INJURY DESCRIBE HOW INJURY OCCURRED
<br />OR PENDING INVESTIGATION (Specify)
<br />30o. 30b. 30c. M 30d.
<br />INJURY AT WORK ►LACE OF INJURY- At home, far., street, factory, LOCATION STREET OR R.F.D. No. CITY OR TOWN STATE
<br />(Spec,fy Y.. or No) office building, etc. (Sp-ify)
<br />3De. j30f. 30g.
<br />WHEN THIS WPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />STATE ,DE Ak' T- 14E -1,T OF HEALTH, LT CERTIFIES THE ABOVE TO BE
<br />A T�A "CbPY -0j AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />DEPARTMENT O'F *;HEALTH, BUREAU OF VITAL STATISTICS, WHICH
<br />IS ,TIE LEGAL jD,EPQSLTORY FOR VITAL RECORDS.
<br />41 -110
<br />DIRECTO'R.OF ti�TAL STATISTICS AND A!)SISTANT STATE REGISTRAR
<br />LINCOLN, NERI�ASKA I Issued Jarsary 25, 1983
<br />WHEN THIS WPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />STATE ,DE Ak' T- 14E -1,T OF HEALTH, LT CERTIFIES THE ABOVE TO BE
<br />A T�A "CbPY -0j AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />DEPARTMENT O'F *;HEALTH, BUREAU OF VITAL STATISTICS, WHICH
<br />IS ,TIE LEGAL jD,EPQSLTORY FOR VITAL RECORDS.
<br />41 -110
<br />DIRECTO'R.OF ti�TAL STATISTICS AND A!)SISTANT STATE REGISTRAR
<br />LINCOLN, NERI�ASKA I Issued Jarsary 25, 1983
<br />
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