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<br />PHS- 798(VS) REV. 4 -57
<br />DEPARTMENT OF PUBLIC HEALTH,
<br />EDUCATION AND WELFARE
<br />BIRTH NO. 1`2,6-- - - - - --
<br />STATE OF NEBRASKA "COPY i"-"
<br />DEPARTMENT OF HEALTH Apf el-Butler-Geddes Funeral Home
<br />Bureau of Vital Statistics
<br />CERTIFICATE OF DEATH STATE FILE NO..:.'�yf )� .P...........
<br />1. PLACE OF DEATH
<br />2. USUAL RESIDENCE (WMre d.e..sed It-d. If inrtit -11 R.sid. brfor. i..i.n)
<br />a. COUNTY
<br />a. STATE D. COUNTY
<br />Hall
<br />Nebr. Hall
<br />D. CITY, TOWN. OR LOCATION
<br />LENGTH OF STAY IN lb
<br />t. CITY. TOWN. OR LOCATION
<br />1c.
<br />GrabdIsland
<br />d Island,
<br />d. NAME OF (If not in hospital, give street address)
<br />d. STREET ADDRESS
<br />X
<br />'T
<br />INSTITUTION Veterans Hospital
<br />C7eburn
<br />e. IS PLACE OF DEATH INSIDE CITY LIMITS? YES NOD
<br />e. IS RESIDENCE INSIDE CITY LIMITS? YES
<br />f. FARM RESIDENCE? YE S8
<br />'
<br />NO
<br />C
<br />rn
<br />4. DATE Month Day Year
<br />(Type or print) Gerald Eugene . ene Sidwell
<br />OF
<br />DEATH 4 3 666
<br />_
<br />5. SEX 6. COLOR OR RACE 7. MARRIED 12 NEVER MARRIED ❑ 8. DATE OF BIRTH
<br />9. AGE (In years IF UNDER 1 YEAR F UNDER N HRS.
<br />M. W_. WIDOWED ❑ DIVORCED El - i -12
<br />Taal birthday) Month. Dow Hwr. Mi..
<br />54
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<br />Custodian
<br />env
<br />Benedict Nebr.
<br />USA
<br />13s. FATHER'S NAME
<br />13b. MOTHER'S MAIDEN NAME
<br />14. NAME OF HUSBAND OR WIFE
<br />Lawrence Sidwell
<br />Jennie Jo LSon
<br />Hazel Sidwell -
<br />15. WAS DECEASED EVER
<br />IN U. S. ARMED FORCES?
<br />16, SOCIAL SECURITY NO.
<br />17. INFORMANT Address
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<br />0
<br />=-
<br />INTERVAL BETWEEN
<br />PART 1. DEATH WAS CAUSED BY-
<br />IMMEDIATE CAUSE (a) Massive upper gastrointestinal hemorrhage
<br />ONSET AND DEATH
<br />Condilion8, if any. DUE TO (b)
<br />c� D
<br />which gave ria [o
<br />�y
<br />�j
<br />above cause �a)•
<br />slating the under- DUE TO (r)
<br />lying cause (asl.
<br />Z
<br />C
<br />PART II. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE
<br />PART III. IF FEMALE, WAS THERE A
<br />WAS AUTOPSY
<br />t
<br />CONDITION GIVEN IN PART I(a)
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />PERFORMED?
<br />U
<br />YES ❑ NO ❑
<br />YES ❑ NO ❑
<br />H
<br />2Oa. ACCIDENT SUICIDE HOMICIDE
<br />2(16. DESCRIBE HOW INJURY OCCURRED. (Enter nature of injury in Part I or Part 11 of item 18.)
<br />W
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<br />20c TIME OF Hour Month, Day, Year
<br />u
<br />INJURY a. m.
<br />200109378
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<br />p. m.
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<br />20d. INJURY OCCURRED
<br />20t. PLACE OF INJURY (e. g., in or about home,
<br />20f. CITY, TOWN. OR LOCATION COUNTY STATE
<br />WHILE AT C] NOT WHILE C]
<br />farm, factory, street, office bldg., etc.)
<br />WORK AT WORK
<br />0
<br />C0
<br />Death occurred at m on the date stated above; and to the beat of my knowledge, from the causes stated.
<br />22a. SIGNATURE (Degree or title)
<br />22b. ADDRESS
<br />E SIGNED
<br />Dr. Robert Munch M.D.
<br />r b'
<br />co
<br />•-}
<br />23b DATE
<br />23[. NAME OF CEMETERY OR CREMATORY
<br />23d. LOCATION (City, town. or county) (State)
<br />RBurial'fy)
<br />- -66
<br />West L e r' 1
<br />Grand Island Nebr.
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<br />PHS- 798(VS) REV. 4 -57
<br />DEPARTMENT OF PUBLIC HEALTH,
<br />EDUCATION AND WELFARE
<br />BIRTH NO. 1`2,6-- - - - - --
<br />STATE OF NEBRASKA "COPY i"-"
<br />DEPARTMENT OF HEALTH Apf el-Butler-Geddes Funeral Home
<br />Bureau of Vital Statistics
<br />CERTIFICATE OF DEATH STATE FILE NO..:.'�yf )� .P...........
<br />1. PLACE OF DEATH
<br />2. USUAL RESIDENCE (WMre d.e..sed It-d. If inrtit -11 R.sid. brfor. i..i.n)
<br />a. COUNTY
<br />a. STATE D. COUNTY
<br />Hall
<br />Nebr. Hall
<br />D. CITY, TOWN. OR LOCATION
<br />LENGTH OF STAY IN lb
<br />t. CITY. TOWN. OR LOCATION
<br />1c.
<br />GrabdIsland
<br />d Island,
<br />d. NAME OF (If not in hospital, give street address)
<br />d. STREET ADDRESS
<br />HOSPITAL OR
<br />INSTITUTION Veterans Hospital
<br />C7eburn
<br />e. IS PLACE OF DEATH INSIDE CITY LIMITS? YES NOD
<br />e. IS RESIDENCE INSIDE CITY LIMITS? YES
<br />f. FARM RESIDENCE? YE S8
<br />NO
<br />NO []
<br />3. NAME OF First Middle Last
<br />DECEASED
<br />4. DATE Month Day Year
<br />(Type or print) Gerald Eugene . ene Sidwell
<br />OF
<br />DEATH 4 3 666
<br />_
<br />5. SEX 6. COLOR OR RACE 7. MARRIED 12 NEVER MARRIED ❑ 8. DATE OF BIRTH
<br />9. AGE (In years IF UNDER 1 YEAR F UNDER N HRS.
<br />M. W_. WIDOWED ❑ DIVORCED El - i -12
<br />Taal birthday) Month. Dow Hwr. Mi..
<br />54
<br />10a. USUAL OCCUPATION (Give kind of work done
<br />106. KIND OF BUSINESS OR INDUSTRY
<br />11. BIRTHPLACE (Slate or foreign country)
<br />12. CITIZEN OF WHAT OOUNTRY?
<br />during most of working life, even if refired)
<br />Custodian
<br />Gr Island Schools
<br />Benedict Nebr.
<br />USA
<br />13s. FATHER'S NAME
<br />13b. MOTHER'S MAIDEN NAME
<br />14. NAME OF HUSBAND OR WIFE
<br />Lawrence Sidwell
<br />Jennie Jo LSon
<br />Hazel Sidwell -
<br />15. WAS DECEASED EVER
<br />IN U. S. ARMED FORCES?
<br />16, SOCIAL SECURITY NO.
<br />17. INFORMANT Address
<br />(Y- no, or - kn...
<br />(if - o- mar or dw,. of -ies)
<br />es
<br />Ti1G12
<br />507 0 7 7770
<br />Ars. Hazel Sidwell Grand Island Nebr.
<br />18, CAUSE OF DEATH (Enter only one cause per line fnr (a), (b), and (c).]
<br />INTERVAL BETWEEN
<br />PART 1. DEATH WAS CAUSED BY-
<br />IMMEDIATE CAUSE (a) Massive upper gastrointestinal hemorrhage
<br />ONSET AND DEATH
<br />Condilion8, if any. DUE TO (b)
<br />which gave ria [o
<br />above cause �a)•
<br />slating the under- DUE TO (r)
<br />lying cause (asl.
<br />Z
<br />C
<br />PART II. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE
<br />PART III. IF FEMALE, WAS THERE A
<br />WAS AUTOPSY
<br />t
<br />CONDITION GIVEN IN PART I(a)
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />PERFORMED?
<br />U
<br />YES ❑ NO ❑
<br />YES ❑ NO ❑
<br />H
<br />2Oa. ACCIDENT SUICIDE HOMICIDE
<br />2(16. DESCRIBE HOW INJURY OCCURRED. (Enter nature of injury in Part I or Part 11 of item 18.)
<br />W
<br />W
<br />❑ ❑ ❑
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<br />J
<br />It
<br />20c TIME OF Hour Month, Day, Year
<br />u
<br />INJURY a. m.
<br />O
<br />p. m.
<br />W
<br />20d. INJURY OCCURRED
<br />20t. PLACE OF INJURY (e. g., in or about home,
<br />20f. CITY, TOWN. OR LOCATION COUNTY STATE
<br />WHILE AT C] NOT WHILE C]
<br />farm, factory, street, office bldg., etc.)
<br />WORK AT WORK
<br />21 1 attended the deceased from to and last saw Aim alive on
<br />Death occurred at m on the date stated above; and to the beat of my knowledge, from the causes stated.
<br />22a. SIGNATURE (Degree or title)
<br />22b. ADDRESS
<br />E SIGNED
<br />Dr. Robert Munch M.D.
<br />Grand Island Nebr.
<br />r
<br />23a. BURIAL. CREMATION.
<br />23b DATE
<br />23[. NAME OF CEMETERY OR CREMATORY
<br />23d. LOCATION (City, town. or county) (State)
<br />RBurial'fy)
<br />- -66
<br />West L e r' 1
<br />Grand Island Nebr.
<br />24. DATE RECD. BY REGISTRAR
<br />25. REGISTRAR'S SIGNATURE
<br />26. NAME OF MORTUARY ADDRESS
<br />A Island.Nebr.
<br />The South Fifty Four (54) feet of Lot Five (5), Block Twelve (12), Schimmer's Addition
<br />to the City of Grand Island, Hall County, Nebraska.
<br />
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