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STATE OF NEBRASKA <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEP4TPLE T(Qf llL LT'H,AND <br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OFT EtbrIIAJAL OOkb ON <br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERI( ES,::,1g14lj RDS 1 <br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS:: - `~ ! <br />DATE OF ISSUANCE <br />JAN 112016 20200083.4 <br />LINCOLN, NEBRASKA <br />STATE OF NEBSASE.A <br />n»�waT�tENT OF HEALTH <br />=A$S ?ANT STATE `:::qFp413,7740itPat-A <br />,JI t? i <br />�cc <br />sucAT1ON AND WNITANZ - <br />BlEeew Of ;' <br />CERTIFICATE OF DEATH ssAzs nus' 310 �..........._..:__._. <br />am* No. 126_ <br />1. MAGE N KATIE <br />. COUNTY e • d 3° <br />2. wow Ut IIIE(Wk..d.r..dw r1 . s«i+rwl.v./i.tor..) <br />2. <br />STATE b. COUNTY <br />Nebraska Hall <br />1 <br />14 <br />e. CITY. TOWN. OR LOCATION <br />b. CITY. TOWN. OR LOCATION <br />Grand Island <br />t. LENCTN OF STAY IN <br />Grand Island <br />I. NAME <br />� ORi i/ Not hi . Oa Mutt.11►aN) <br />HOSPIINSTITUTION Lutheran Memorial Hospital <br />IL STREET ADDRESS• <br />1809 North Huston St. <br />RESIDENCE, YES <br />t. IS PLACE OF DEATH NODE CITY LIMlTS1. YES tiOusD <br />e. K RESIDENCE. INSIDE CITY LIMITS, <br />TESNO l= V TARN <br />LJ JXINIS <br />3. OF Find JNtddk L 1 <br />4. DA " . DUV Y.wwvs* <br />OF <br />NAME <br />DEATH ' • May 2, 167 <br />(nH NCEASEO <br />Juni° Arthur Richardson <br />WNW. <br />S. SEX <br />$ COLOR OR RACE <br />White <br />7. MARRIED 'NEPER MARRIED G <br />MOON= 1 DIVORCED 03an. <br />3. DATE OF NINTH <br />18 , 1924 <br />9. AGE BiN34.F3 <br />.4N 3 <br />• URoa1:YEAR <br />M.MA. <br />D.Mu Ma. <br />Dapsr. <br />WNW <br />Male <br />KG.. USUAL OCCUPATION <br />twist nog •I working <br />I <br />4 <br />(OiNkind NMNfoiefoieKMN <br />We, aew iJ stat!) <br />10MOWSUSINESSOR INDUSTRY <br />Railroad . <br />11. IIRTNPLACE (8/(8/411.sr JI * awstrE) <br />Norfolk. Nebraska <br />1:. Cf 11/NAT <br />USA <br />Machinist 14. NAME OF HUSBAND OR WIFE . <br />13a. FATHER'S NAME 13b. MOTHER'S MAIDEN NAME i <br />Richardson Clara Dreger Daisy Starkey Riohardson <br />Mack <br />1S• WAS DECEASED EVER N1 U. S. ARMED FORCES/ NWaft SECURITY NO. <br />17. MiPMMAMT 18e1°rth <br />Mrs. Daisy Richardson,` Grand: Island,Nebr. <br />Huston <br />EETVIUN <br />, v... ......3/4...., U/W...Nw 11. Mho N swirl <br />Yes ' WW II 506-20-1927 <br />IS. GAMIC K morn (sate: is* ant awe. (0). sad 0)4 <br />INTERVAL <br />AND <br />PART I. DEATH WAS CAWED BY: <br />!�^ <br />Rid <br />IMMEDIATE CAUSE (.) x-' '�"� <br />.� ti <br />A`" <br />ill i <br />. iJaaF. <br />wAieA WI e ~ <br />.e..e e.Naea)• <br />stating sin rider- <br />DUE TO (0) ..1- -6i'W-1ad <br />1niaa )at. <br />DUE TO (t) <br />19. w A1RflGlS`► <br />east <br />NN TO DEATH BUT NOT RELATED TO THE WRNNIAL DHEA![ <br />PART IR. 4 PIMALE. WAS 101* A <br />PE <br />►• <br />PART 11. OTI SISNOM MT CCWOITlONS coommu <br />OOIpTNNf QWEN M PART 1(4) <br />MONANCY IN 7111 PAST 3 MONTHS? <br />YES g no CIYES <br />1 <br />❑ NO <br />ACCIDENT SUICIDE HOMICIDE <br />❑ 0 0 <br />MOM NOW INJURY OCCURRED. (ERIte New a/Wary is Pin K leve II NSM 10 <br />20 MOM20.. <br />• <br />tee. TIME or Hose Meth, Dec Year <br />INJURY a. R1. <br />s••- <br />N- <br />STATE <br />SW. WWII' OCCURRED i <br />WN AT ❑ NOT WNN.E ❑ <br />WORK AT WORK <br />Imt. PLACE OF INJURY (e.F�_IR N.Awt A.RMWHILE <br />M*•F• ,Ned. Nob, •) <br />Z01 CITY. TM. OR LOCATION COUNT, <br />21. the <br />hoer . '- -.. 1 , to <br />? I and Met saw Zit: Winton <br />I attended <br />Death .d ' 1 • : A* - As on th• dare iota above; and a tM beat et any AwowJed4S. howl rho <br />Naos *tarot <br />oeaar <br />2)'a. MINA 1 NMN) ~` p - <br />'2��G� Ityrs/ <br />DATE SIGNED <br />Ip,c� <br />126.,..-Mie4S <br />� <br />23.. <br />EUMAL. COMA <br />Revoi <br />234. 23t. MANE OF CEMETERY ON CATORY <br />Inc. <br />,lawn Me Qr1ial Park . <br />231. LOCATION (MI.,h1 . N Noah/ ( ) <br />Drapd Island, Nebraska <br />�L 1_. <br />;i»ri aiL. <br />AMOM <br />NTRAR (MOAN'S <br />!1 NAME OF MORTUARY <br />,9 7 Livingaton-Sonder aria, Grand Island,Nebr. <br />