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<br /> " Lot Six (6) , Block Thirty (30) in the Original Town, Now City of �
<br /> , Gz^and Island, Hall County, Nebraska �
<br /> 99 1118 �8 '__.
<br /> I HEREBY CERTIFY THAT THIS IS A TRUE AND EXACT COPY OF THE ORIGINAL A H ����
<br /> CERTIFICATE, .AND THAT I AM AN ACTING FUNERAL DIRECTOR
<br /> oi THE APFEL-BuTi,ER-G�'�DES FLT:I�ERAL ?i0';E.
<br /> STATE Of NEBRASKA-DEPARTMENT OF HEALTH LICENSE NO.
<br /> Amended BUREAU OF VITAL STATISTICS
<br /> °��. 1�, l�s� CERTIFICATE OF DEATH .- .
<br /> OECEDENT-NAME IAST SE7f L-�`�
<br /> FIRST MIDOIE DATE Of OEA H�Mo.,Do�,Yi.) �
<br /> • ,. Leonard I�rancis Forsman z Male � Plover�ber 7, 1950
<br /> RACE-(�.y.,Whi��,�cl,A��.icon ORIGIN/DESCENT(�.p.,Itolion,M��icon, AGE-Imr�:nl�der UNDER 1 YEART� UNOER 1 OAY DATEOf 61RTM(Mo.,Do�,Yi.) �
<br /> Indion,�k. (Sp�ti/r) G�nwa�,Nc.1(Sp�cilr) (yn.i MOS. �OAYS HOURS�MINS.
<br /> .. l•'�iite s. �lmerjcan " �G ; �
<br /> �. eb. y�. � , March 27, 1924
<br /> CI Y ANO STATE Of SIRTH(I!nel in U.S.A.,�� CITIZEN Of WHAT COUNTRY MARMED,NEVEN MARRIEO, NAME Of SVOUSE�ll wil�,gir�maid•n noin�J
<br /> no�n�coun�rr) � WIDOWED,DIVORCED(Sp�tily)
<br /> e.?Ict.au lilin, South Dakota q, i1.S.A, ,o. ;•larried ,,. F'rieda t•f. Scheer
<br /> SOCI S�,[UI�( NlJN�OEb USUAI OCCU►ATION(Gir�4ind o(worl�don�d�riny�w! KIND OF 6USINESS OR INDUSTpY COUNTY Of DEAiH �
<br /> /1 L b.}bo ol�rorkin lil�,�r�ni/r�lir�d) Creyl���nesBus H111
<br /> �:. ,s,. �fana�er � I16. I�o. `
<br /> CITY,TOWN OR IOCATION pI OEAiM INSIOE CtTY LIMIiS NOS►ItAL OR OTMER INSTtTUitON-No��(1I Iw►in�i1A�r, If MpS►.OR INST.Indi����pp�,
<br /> (Sp�cilx ��er No) piv� �d d wuwb�Q OwpaK.w�/E�w...�w..Iny��4w�!Sy«drl
<br /> ,�b Crand Islan�l ,k �es ��d �ut�ieran ,lemorial liospital
<br /> �
<br /> �... In aticnt
<br /> RESIDENCE-STAtE COUNiI' CITY,TOWN OR LOCATION STREEi AND NUMOER INSIDE CITV llr.ut�
<br /> �so. �1eLraska �ss. Ilall �k. Grand Island �sa. lf>18 [•!. I.ouise �sP.��r,,r..e,No
<br /> A E�-NAM fl 13�. YC5
<br /> , MIOOtE lA iNE -hUIOEN NAME fIRST MI DlE U
<br /> ► . L•'mil -�-- T'orsman Christina -- llammerschm!�
<br /> WAS DECEASEO EVER IN U.S.ARMED fORCESt INfORM�NT-NAME-REUTIONSIN►-MAiIING ADDRESS (SiffET OR t.I.D.NO.,CITf OR tOWN,31 r
<br /> ,... ...e..."��„,...o..._..,e�d ae,�o,K..,�., ���a�
<br /> �e. No ,v. :lrs: Frieda Forsman-WiEe-1G18 Gl. Louise--Grand Islancl. �;
<br /> 6URIAl,Cr�ma�ion,R�moval�AT EMETERI'OR CREAAATORY-NAME IOCATION CITY OR TOWN STATE
<br /> ,:o�, io, i�E f
<br /> zo,. 13urial �. z�. Crand Island Cemeter �. Grand Island, Nebraska
<br /> EMlA R �SIGNAiUR �� NO. � FUNERAI NOME-NAME AND ADORESS �STRElT Of�./.D.NO.,CIT/O�TOWN,SiATt,21►)
<br /> 7
<br /> ��. � : �z.��+fel-Eutler-Ceddes 1123 t•1. 2nd, Crand Island, NE. 68801
<br /> � 1 '�� ��'���.d r�. ar�M Nw�.d ewd plo�� d ��b IM _.
<br /> '� • �)�bN�. ' � Z� ���►a�i��1�w.�iwarl�n nA/w iww�N�oN�n,in r�yiwi�w A��M�i��.�d a�
<br /> �A�Nw�.do��ond pl«�awd du�»�M<�uw�y�b1�d.
<br /> ��Z
<br /> 4y� 4�o.fSiyna� endl:N�/� 7Y� q�o.(S:yne��.�ewdl;N�l'
<br /> :> DATE SIGNED�Mo.,Dar.1'••) HOUR Of DE�TM :�t A
<br /> oZ_ 4:t� /Mo. o�. ..1 -
<br /> ��� ��- /U - � �
<br /> 2�6. 2h. � � �nn v W Z� 2�6. 2�c.
<br /> _° DATE Oi DEATM(Mo.,Doy,1'r.) M
<br /> F` e�0 PRONOUNCEDDEAO VRONOUNCEDDEAD�Meur) �
<br /> 7]d. � � p a IMo..Day.Y..)
<br /> V
<br /> NAME AND ADDRESS Of C R IfIER(►MYSICIAN,CORONEKS►MYSICIAN OR COUHTY ATTORNEY)(/ �� ' M
<br /> rP�or Yrinl) -
<br /> � z3, David Colan I1.D. 729 N. Custer, Crand Island � P1E. 68£3t)1
<br /> AEGISTR�R
<br /> ��,�� D�RECEIVFD!Y REGISTRAR(Mo.,Dor,Yr.)
<br /> �,��`j'S , i� , � ,� � ,� i
<br /> sea.�s.o���,.,�'_'_ �- E?c 2 ;,L�s-,,�/��-� i �j��
<br /> 27. IMMEDIATE CAUSE /ER ONIY ONE CAUSE►ER UNE fOR(o),(b),ANO(a)) �—
<br /> �ART � 1nr�nol b�nn�n�w���ewd d.o�w
<br /> --ia� �Cu?Z /1'�YaeA�t/�i9 L 1.clfA.t P T7U.t� ' g-,lO��
<br /> DUE TO,O!AS A CONSEOUENCE Of: � I�r•nol b.�..•.,,e.�•.r��d d.orh
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<br /> _,b� 7Nt.COSC4/L!)TIL �f1��T �iS1A-S� /� y,(�
<br /> DUE i0,04 AS A CONSEQUENCE Of: +�—��-,�b����M���'a��
<br /> t.t .
<br /> ►ART OTNf�SIGNI{KANT CONDITIONS-C�wd��iow�aon�.ib�riny��dw�A►��ner r�lor�d ►AR►IN.li IliulF,w�5 TNf�E A AUTO►51' wA3 C�Sf IIE!l�IIfD 10/�EDICnI
<br /> II /�FGNANCY IN TM!GSi 7 MONTM57 (Spwl�Yo w No/ E1fAMINEI OR CO�ONl�
<br /> Y•.L) No C1 �/ J Is�.��r�r.�w N.1 '`�C.J
<br /> 7B_�vC.� ?9:
<br /> wCCIDWI,SUICIDl,MOMICIOE,UHD(f., D�/f Oi IN1U�1'(Me.,Pu�,vr.) NOUR Of�N/UIIY OESCl��E NOw IN1U�V OCCURII[D —"
<br /> . o�rwaNC�r.vesne.nor+.rs,«,ti�
<br /> 30a. �!�L/�� S JOb �Oc. M JOd,
<br /> IM/U�r AT WO�[ ►UCE Of IN1UR1'-M Aen�,lonw,ar.��,leNOry, IOCATION STfEFi O�R 1D.No.
<br /> ISp«�l�/•�er N�J e11ii�buildinp,��i (Sp•cil�) � CIT/OR TOWN STAT�
<br /> �0.. �01_-------- ��^ --
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br /> STATE DEPARTMENT OF HEALTH , IT CERTIFIES THE ABOVE TO BE
<br /> A TRUE COPY �F AN ORICINAL RECORD ON FILE WITH THE STATE
<br /> DEPARTMENT Or HEALTH, BUREAU OF VITAL STATISTICS , WHICH
<br /> IS THE LEGAL DEPOSITORY FOR VITAL RECORDS .
<br /> ' ��t � e�� - .'=:,
<br /> DIRECTOR OF VITAL STATISTICS AND A.SSISTANT STATF RF.CISTRAR
<br />
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