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� C� !� �� e� -.�.� <br /> � S D � �.� � <br /> n A c n = '.i ` �= M; --a C� rn <br /> = Z , �. _-� , ., � � <br /> c"'i i `!' �` � � � ,�,, `�i � `-o <br /> � � � � � � <br /> �7 S �'� `� � <br /> � _ �� � "f.7 ?a C7 �� C!> <br /> �� _' � <br /> "� t�:� p�'', �. <br /> � . � .�.� 4Y� \S� � <br /> ��� "� v' � � c° <br /> � �;� � r�''. <br /> 1 � ° o <br /> �� <br /> �� <br /> - - gg. 1osssz <br /> WHEW TF�IS COPY CA�S TI�RA/SED SEAL OF THE NEBRASKA HEALTH AND _ S <br /> gySTEIY�IT CERT�S TF�BELOW TO BE A TRUE COPY OF THE ORIG/NAL � _ J � � <br /> THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM,VITAL STATISTIL�SE��1�Wf�EP.f#!.�__ <br /> THE LEGAL DEPOS/TORY FOR VITAL RECORDS. � � _ <br /> -_ �=�� - <br /> DATE OF/SSUANCE - <br /> JUN 2 S 1998 As�s�s���a,�� _= <br /> UNCOLN,NEBRASKA HEALTH AND Hl1�111���ib!�_-- <br /> - - - ---��� <br /> ._ _. .,"STATE OF NEBRAStCy4Y�AR'i'l�NT(3F HEAI.IH AND fi[1MAN S6A �'_ �, ,.�� <br /> VITAL STATISl'ICS -- -- <br /> CERTIFICATE OF DEATH = ___ <br /> t.DECEDENT-NAME FIRST MIDDLE �AST 2.SEx 3.DATE OP DEATH lMOntn.Day.Year1 <br /> Mildred Emil Root Female June 11 1998 __ <br /> 4.CiTY AND STATE OF BIRTH /tlnWn USA..�am9COUnhyl Sa.AGE-Laat BirthOay UNDER 1 VEAR UNDER i DAV 6.DATE OP BIRTH /MOnfh.Day YearJ <br /> �vrs.i 93 so.Mos i DAVS SC.HOURS' MINS October 02�1904 <br /> Ed ar Nebraska <br /> 7 SOCIAL SECURTIY NUMBER 8a.PLACE OF DEATH , <br /> SO/�Z-4YLZ _ HOSPITAL�. � �npaGern OTHER� � Nursmg Home <br /> Bb FnCIUTV-Name /dra�msfimtian.9rveshaefantlnumber) � EROutDaGent -�_ � ResiCence <br /> Mary Lanning Memorial Hospital ❑ ��A ❑ a°e"s°e"�" __ <br /> Bc CiTV TOWN OA LOCA710N OF�EAT1! ,8C INSIDE CITV LIMI75 Be.COUN7V OF DEATIi <br /> gastings �85 � Na ❑ Adams <br /> 9a.RES�DENCE-STA7 E 9D.WUNTV 9c.CITV.TOWN OP LOCATION 9tl.STiiEET AND NUMBEH (I�ludingZip Code/ 9e INSIDE CITV UMITS <br /> Nebraska Adams Hastiu s 233 N. Hastin s 68901 ''e5�"°❑ <br /> 10.RACE�(e.g..Whne.Black.Amencan Intlian. 11.ANCESTRV le.q..�lalian.Mezwan.Garman,etcl 0 �2.❑MARRIED �W�DOWED 13.NAME OF SPOUSE Ill wAe.grve maiden namel <br /> etc.I150eory1 IS�'�1'� � NEVER DIVORCED <br /> M RRI Geor e Root deG .____ <br /> i 4a.USUAL OCCUPATION lG�ve kind d wpk Dane dunng nws� O�� 1<b.KIND OF BUSMESS INDUSTRY �� 1 15.EDUCATION �SpetiH only highes�graae comple�ed� <br /> o/work�rrg lile.even i/retiredl �),..� Elememary or SeconOary 10-t 21 Colleqe i��4 0���i <br /> 'Re istcred Nurse Private Hos ital --- <br /> 16.FATHER-N4ME FIRST MIDDIE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br /> John Branstitre Kathryn Perry __ __ <br /> 78.WAS DECEASED EVEAiN US ARME�FORCES? � 19a.INFORMANT-NAME <br /> �Ves�o.ur•.�k� iii�es.ynr.war ard daros of sarvice.l <br /> i T�� 1 Binfi t on -- <br /> 19p INFOHMANT "dAIUNG ADORESS ISTREET OR R.F.D NO..CITV OA TOWN STATE.ZIP) <br /> -�, � th Ju ' t a 68955 --- <br /> BA MER IGNATU'1.8 UCENSE O ' la. 51 16N �21b.6A'fE �21C CEMETEFY OF CaEMATURV NAME <br /> 1210 �8���� �Removai 06/13/1998 Rosedale Cc�mete� __ <br /> U Al HO E�N . 21tl.CEMETERY OA(:AEMATOR�LOCATION CITV CR TOWN STP.TE <br /> ivin ston- utler-Voliand Funeral Home ❑°fe"�'�" ❑°ora"� Hall Count Rural,NE ____ <br /> 22b.FUNERAL HOME ADG�E55 (STREET OR R.F.D.NO..CI7V OA TOWN.STATE,ZIP) . <br /> 1225 N. Elm Ave. Hastin s,NE,68901 ---- <br /> 23. IMMEDIATE CAUS° (ENTEN ONLY ONE CAUSE P R LINE FOA lal.IDI.AND�c11 � imer ai between onsei ana neai�� <br /> PART \� i - <br /> I �� I <br /> Ial <br /> I Interval betw¢en onsel and oeain <br /> DUE TO,OR AS A CONSEO OF�. i <br /> ��I�l � <br /> �DI -- - � - -_�_ <br /> L`aE i0.OR AS n CONSEOUENCE OF� i Intervai between onsat ana oeat� <br /> i <br /> i <br /> ��� � - <br /> OTHEA S�GNIFICANT CONDI710NS-CaMitbns contribu6rg W Me tleaN but nW�elaleA PART III IF FEMALE.WAS THERE A ' 2a AUTOPSV ZS_E%M�INER OA COAONER>MEDICAL <br /> pqqT PREGNANCV IN THE PAST 3 MONTHS <br /> il Yes No <br /> �Aqes 10-SM1I Yes No Yes No _ <br /> p5y. . 26b.�ATE OF INJURY �MO.Oay.YcJ 26c.HOUR Of INJURY 26d.DESCRIBE HOW INJURY OC URPED <br /> � Acctlent � Untlelerm�ne0 M <br /> � SmoOe � �'e�a��ng 26e.INJUA�AT WORK 26t�PLCe�Oai�e,R��5�����arm.5treet�at�Ory- 26g.LOCATION STREET OR R.FD.NO. C�T�OR TO�NN STATE <br /> tM1 <br /> � Hom�cide ���esugaUOn I Yes� No� _ .____ <br /> 27a DA�E OF DE H lMO..Oay Vrl 28a.DATE SiGNED iMO.Day.YrJ 28b TiME OF DEATH <br /> $N - �' � �J'� 2gc.pRpNOUNCED DEAD /MO,.Day,YrJ 28d.PRONOUNCEO DEAD (HOmr M <br /> � 27D DATE S�GNED /MO.. ay Vr/ 27a TIME OF DEATH 6� <br /> E n-' I �: / 6� <br /> g �'o v �V � M g w�� M - <br /> �� 27A To Me Dest ol m nowleCge. occuned a�Ihe time,tlate antl daee and Oue Io Ihe �� a z� me tnme.date and D a'ce 1antl 0 to the esusesl st�gp.���atn occune0 at <br /> causelsl stat .•.-• . � � <br /> �S nalure and T�le „'�w' -namre aM 7ine ► <br /> 29.DID TOBACCO USE CONTFIBUTE TO TH DE 7H? 30.a HAS ORGAN Ofi TIS UE DONATION BEEN CONSIDEfiED7 30.D WAS CONSENT GRAN7ED7 <br /> � VES � NO NKNOWN �S' � NO � VES �� <br /> 31 NAME AND ADORESS OF CERTIFIER�PHYSICIAN,COFlONEA�S PHYSICWN OR COUNTV ATTORNEY) lType d PrinU " <br /> Dr. James W. Hervert, 2115 N. Kansas, Hastin s, Nebraska 68901 <br /> � 32b.DA7E FILED BY REGISTRAR /MO..Day.nJ <br /> 32a.REGISTRAR � <br /> The Southeast Duarter (SE1/4) of Section Twenty-tour (24), ToWnship Nine (9) North, Range Eleven (11> uest of <br />