|
ac_-_
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECD ON FILE -iWTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTf", WfNCH 14
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _ r
<br />DATE OF ISSUANCE _
<br />AUG 2 2 2001-
<br />ASSISiFA1flT STATE REGISTRAR'_ -'
<br />LINCOLN, NEBRASKA
<br />200109171
<br />PHS- 798(VS) REV, 4-37
<br />DEPARTMZNT OF PUBLIC HEALTH.
<br />EDUCATION AND WELFARE
<br />BmTH No.126._
<br />HEALTH AND
<br />STATE OF NEBRASKA
<br />DEPARTMLNT OF HEALTH
<br />Bureau of Vital Statistics
<br />CERTIFICATE OF DEATH
<br />64 0323,
<br />STATE rn.E NO ........ ._ ................. _........
<br />1. PLAW a MCATIM
<br />L USUAL 11M99W (IF&w*A...dw fl�M.ew.w: R�d.,rA,r «.v:..:•,)
<br />. COUNTY
<br />�Sv�
<br />.
<br />Hall
<br />u Hal 1
<br />'. CITY. TOWN. OR LOCATION
<br />C. LENGTH Of STAY K/ Ul
<br />t. CITY. TOWN. OR LOCATION
<br />d. NAME Or (I/ art in homma1. On atnet eddrea)
<br />d. STREET ADDRESS
<br />HOSPITAL OR
<br />NSTITUTK?N 2518 T ' o
<br />251P w- K
<br />t. IS PLACE Or DEATH INSIDE CITY LIMITS? YES:Q NO 0
<br />e. IS RESIDENCE INSIDE CITflul:,Irffi YES
<br />/. FARM RESIDENCE/ YES
<br />I
<br />NO
<br />NO
<br />3. FBat mime Last
<br />4. DATE A"ad Day row --
<br />IKor
<br />T
<br />=
<br />S. SEX
<br />6 COLOR 00 RACE
<br />7 MARRIED 0 MEYERMAMIKED
<br />6• DATE OF BNTN
<br />9 AG (to PW
<br />1'71
<br />T�
<br />Y'_
<br />Z
<br />n
<br />O
<br />�-� ry
<br />C
<br />Female
<br />e
<br />W
<br />=
<br />D
<br />v
<br />x
<br />10s. USUAL OCCUPATION
<br />"ia i
<br />►-�
<br />Q ..4
<br />O
<br />Env
<br />loo Housewife
<br />Rome
<br />Camn Grove. I
<br />U S'
<br />n
<br />BIb. MOTHER *S MAN" NAME
<br />N
<br />Scobt Townsend
<br />Mae Jennie to is
<br />ruqt in MC.
<br />IS. WAS DECEASED EVER
<br />IN U. S. ARMED FORCES?
<br />16. SOCIAL SECURITY NO.
<br />IT WPPOIWAAUT Address
<br />m
<br />_:_q m
<br />O
<br />Vleminr, Grpmd Tmi:iind-
<br />N. CAUL N BRATN IDor @Wp ant hatpw (a), (5), and (t).)
<br />INTERVAL BETWpJ1
<br />PART 1. DEATH WAS CAUSED BY:
<br />!4
<br />ONSET AND TH
<br />IMME0IATE CAUSE (e) he" 'CLj"
<br />'00i'7'0
<br />M-�
<br />a
<br />O
<br />asaNr t�:a. (A1.
<br />s
<br />ofeamr the Bn4r DUE TO (t) _
<br />trig team low.
<br />-
<br />C
<br />PART 11. OTIO SMI&FICANT CoNO"W O CbNInNW MB To DEATH an WX REIATED To flK TLoWAL DISEASE 2=I= Crm N PMT I(a)
<br />17. WAS AUTOPSY
<br />►'
<br />PERFORMED?
<br />3
<br />YES ❑ two
<br />fTi
<br />v
<br />D' CF?
<br />O
<br />Cri
<br />e —F
<br />20t, TIME OF Hoer JWmatA, Dep. Yea
<br />INJURY •. M.
<br />is
<br />W
<br />=
<br />20d. INJURY OCCURRED
<br />Mr. PLACE OF INJURY (t. r., M or a5wt" m,
<br />201. CITY. TOWN. OR LOCATON COUNTY STATE
<br />WNK 9 AT 0 NOT WHILE 0
<br />JKN, Hderr. cued, OAW Sty., ere.)
<br />CD
<br />WORK AT WORK
<br />21. I Attended the deoessd / , eo - _and last mew w alive on -
<br />d
<br />Dent occur t r en on the date stated above; And to the beet of my knowledge. /rom the causes stated.
<br />■R (Dq►er M fYle�
<br />SS
<br />ne. DATE SIGNED
<br />WAATKeI
<br />DATE 23e.
<br />MAME Or CEMETERY OR CREMATORY
<br />23d. LOCATION ( r. pun. a temp) (State)
<br />(s )
<br />Nebr.
<br />D. BY IIEOIBTRAR
<br />Wm5m
<br />R[ A ICNATUR
<br />2L NAME OF MORTUARY A _
<br />Grand I Nebr.
<br />- 196
<br />„
<br />Apfel- Butler- Geddes, ,
<br />Ln
<br />f
<br />F�
<br />ac_-_
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECD ON FILE -iWTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTf", WfNCH 14
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _ r
<br />DATE OF ISSUANCE _
<br />AUG 2 2 2001-
<br />ASSISiFA1flT STATE REGISTRAR'_ -'
<br />LINCOLN, NEBRASKA
<br />200109171
<br />PHS- 798(VS) REV, 4-37
<br />DEPARTMZNT OF PUBLIC HEALTH.
<br />EDUCATION AND WELFARE
<br />BmTH No.126._
<br />HEALTH AND
<br />STATE OF NEBRASKA
<br />DEPARTMLNT OF HEALTH
<br />Bureau of Vital Statistics
<br />CERTIFICATE OF DEATH
<br />64 0323,
<br />STATE rn.E NO ........ ._ ................. _........
<br />1. PLAW a MCATIM
<br />L USUAL 11M99W (IF&w*A...dw fl�M.ew.w: R�d.,rA,r «.v:..:•,)
<br />. COUNTY
<br />�Sv�
<br />.
<br />Hall
<br />u Hal 1
<br />'. CITY. TOWN. OR LOCATION
<br />C. LENGTH Of STAY K/ Ul
<br />t. CITY. TOWN. OR LOCATION
<br />d. NAME Or (I/ art in homma1. On atnet eddrea)
<br />d. STREET ADDRESS
<br />HOSPITAL OR
<br />NSTITUTK?N 2518 T ' o
<br />251P w- K
<br />t. IS PLACE Or DEATH INSIDE CITY LIMITS? YES:Q NO 0
<br />e. IS RESIDENCE INSIDE CITflul:,Irffi YES
<br />/. FARM RESIDENCE/ YES
<br />I
<br />NO
<br />NO
<br />3. FBat mime Last
<br />4. DATE A"ad Day row --
<br />IKor
<br />t?i>k a p►!at) Celia C. a
<br />METH Z 2
<br />S. SEX
<br />6 COLOR 00 RACE
<br />7 MARRIED 0 MEYERMAMIKED
<br />6• DATE OF BNTN
<br />9 AG (to PW
<br />I Tam
<br />Y'_
<br />M••�r.R AI
<br />Female
<br />e
<br />WIDOWED D?VOOKED
<br />t -�
<br />10s. USUAL OCCUPATION
<br />"ia i
<br />105. KNDOF MISINESSOR KWItSTRY
<br />11. BIRTHPLACE (Safe or prelln teelntrr)
<br />1 tVI M a ~T Coup""?
<br />� nod � b lMak�
<br />loo Housewife
<br />Rome
<br />Camn Grove. I
<br />U S'
<br />IIa. F THER S NAME
<br />BIb. MOTHER *S MAN" NAME
<br />NAME Or HUSBAND OR WIFE
<br />Scobt Townsend
<br />Mae Jennie to is
<br />ruqt in MC.
<br />IS. WAS DECEASED EVER
<br />IN U. S. ARMED FORCES?
<br />16. SOCIAL SECURITY NO.
<br />IT WPPOIWAAUT Address
<br />1
<br />Vleminr, Grpmd Tmi:iind-
<br />N. CAUL N BRATN IDor @Wp ant hatpw (a), (5), and (t).)
<br />INTERVAL BETWpJ1
<br />PART 1. DEATH WAS CAUSED BY:
<br />!4
<br />ONSET AND TH
<br />IMME0IATE CAUSE (e) he" 'CLj"
<br />'00i'7'0
<br />tditbna, it /p� /e. DUE TO (A)
<br />asaNr t�:a. (A1.
<br />s
<br />ofeamr the Bn4r DUE TO (t) _
<br />trig team low.
<br />-
<br />C
<br />PART 11. OTIO SMI&FICANT CoNO"W O CbNInNW MB To DEATH an WX REIATED To flK TLoWAL DISEASE 2=I= Crm N PMT I(a)
<br />17. WAS AUTOPSY
<br />►'
<br />PERFORMED?
<br />3
<br />YES ❑ two
<br />F
<br />Me. ACCIDENT SUICIDE HOMICIDE
<br />205. DESCRIBE NOW INJURY OCCURRED. (Ebro astwe y!R}nrr in Part I or Port U yitem 16.)
<br />0 0 0
<br />20t, TIME OF Hoer JWmatA, Dep. Yea
<br />INJURY •. M.
<br />is
<br />W
<br />=
<br />20d. INJURY OCCURRED
<br />Mr. PLACE OF INJURY (t. r., M or a5wt" m,
<br />201. CITY. TOWN. OR LOCATON COUNTY STATE
<br />WNK 9 AT 0 NOT WHILE 0
<br />JKN, Hderr. cued, OAW Sty., ere.)
<br />WORK AT WORK
<br />21. I Attended the deoessd / , eo - _and last mew w alive on -
<br />d
<br />Dent occur t r en on the date stated above; And to the beet of my knowledge. /rom the causes stated.
<br />■R (Dq►er M fYle�
<br />SS
<br />ne. DATE SIGNED
<br />WAATKeI
<br />DATE 23e.
<br />MAME Or CEMETERY OR CREMATORY
<br />23d. LOCATION ( r. pun. a temp) (State)
<br />(s )
<br />Nebr.
<br />D. BY IIEOIBTRAR
<br />Wm5m
<br />R[ A ICNATUR
<br />2L NAME OF MORTUARY A _
<br />Grand I Nebr.
<br />- 196
<br />„
<br />Apfel- Butler- Geddes, ,
<br />Lot Fourteen (14), Block Eleven (11), Ashton place, an Addition to the City o{ Grand
<br />Island, 'Pall County, Nebraska.
<br />4
<br />4
<br />`J1
<br />a
<br />
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