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PHS- 711EV81 REV 6 -1'1 IN STATE OF NEBRASKA <br />DEPARTKENT OF PUBLIC HEALTH, DarARTMENT OF REALTE <br />12VQN AND WELFARE Bureau of Vital Statistics <br />SIR NzO 126......,. CERTIFICATE OF DEATH STATE FILE NO. <br />I PLACE OF MATH 2 UBUAI. MWMNCC I WAwr r.N.r I -d r /.N...t.I.•N d. ►Nr..d.M.M•) <br />e COUNTY • STAY [ D 11-NO.- Nw <br />COUNTY <br />Hall Nebr Hall <br />D. CITY TOWN. ON LOCATION r LENGTH Of STAY IN IS ( r CITY. TOWN. OR LOCATION <br />Grand Island _ 20 yrs _ Grand Island <br />�. d. NAME Or !I net IN Ao.pltd, Corr street ddrfa.l It STREt T ADDRESS <br />HOSPITAL OR <br />INSTITUTION 1729 Idlewood Lane _ 1729 Idlewood Lane <br />Z <br />Y r IS PLACE Of DEATH INSIDE CITY LIMITST YES L& NO U r. IS RESIDENCE INSIDE CITY LIMITS, YES IF FARM RESIDENCEr YES <br />2 NO 1 NO <br />I IEAM1 Or Fbd .SINdlt =_ - Loft I DATE Month Da, Yea <br />a T,p o Cp 1Nr) Robert Eugene Lichty DEATH July 4, 1967 <br />S St 6 COLOR OR RACE 7— LJ E DATE Of BIRTH 9 AGE (1n Fee's IF UNDER I YEAR UNARM <br />J MARRIED NEVER MNRRIED May 27 1922 (Mf rjl�d• /) XwH4 O•w sew.. Xr. <br />M W WIDOWED ❑ DIVORCED y s 45 <br />14 USUAL OCCU ►AT ION IGwe 111Ad of wort done 106 RIND Of BUSINESS OR INDUSTRY 11 BIRTHPLACE IilNr or foreign country) 12 CITIZEN OF WHAT CIOJ.ITRY1 <br />du�IN o! wee Yln/ 71N. rxn If rrnrrd! <br />Ci ce .4anager Cren Finance C 3eatriceit Nebr USA <br />Ile. FATHERS NAME 13b. MOTHER S MAIDEN NAME Id. NAME OF HUSBAND OR NIFE <br />�i Galen Lichty(dec) Hazel Sample Ruth(Thinm) Lichty <br />1S WAS DECEASED EWER 1M U S ARMED FORCESI 16 SOCIAL SECURITY NO 17 INFORMANT Addrt•• <br />i r.« ...r eW. • I <br />yes 9- 23-42%12- -45 505 -11, -0646 Mee. 3uth Lichty; Grand Island, Nebr <br />I <br />19 CAUEI OF 10CAT114 JEntrr *Nl/ AN, ra— Per IINr /er to), III), •nd Irl ( INTERVAL BETWEEN <br />p PART I DEATH WAS CAUSED BY Cci rCjj r�C d7iPSt OMSETcAMO_QEOT.1 <br />7 IMMEDIATE CAUSE (•) _- - - -�— III- L -AI -- <br />(70111110"'. Ilea F. DUE TO (6) <br />Coronary thrombosis 5 min. _ <br />c wAtrA parr rIx to <br />T abOY( C•tl It (•� <br />196F./ fAt under- DUE TO (r) <br />112 IF Comm Inst IhR ; <br />NAT Ic -sees uckww.- �nw -MYS �^"TS ^� i! Ste. `q' �• "'� �^ • -: Z�Y'�:: �,��ay. il. IF IEM-E. 'rV Af I.,., A '� <br />L <br />I- CONDITION GIVEN IN PART 1(4) I PREGNANCY IN THE PAST 7 MONTHS, PERFORMED? <br />V YES ❑ NO ❑ YES ❑ NO E) <br />I= We ACCIDENT SUICIDE HOMICIDE 206 DESCRIBE HOW INJURY OCCURRED (Enter neure o /Injury In Port 1 or Pat 118fifta t1.) <br />MNj ❑ ❑ ❑ <br />20C TIME Of flour MORIA, Da,, Year <br />INJURY O. 111. <br />yy p. In <br />7 2Dd INJURY OCCURRED 30f ►LACE OF INJURY (t. It. M or ehoul Aoau, 2(lf CITY, TOWN. ON LOCATION COUNTY STATE <br />WHILE AT C] HOT WHILE C: /ern1, /Alt01I. d/rd, oeEfr hide" dr.) <br />�I WON AT WORK Iunknvwn <br />ZE 1 Ott* n dad flora d-e.. /r4p - __-- ._I -.I,I _. -__ __ , to . -__._- •nd 1•Nf •RW him R /ir• on <br />Dooth occurred At �' - -1'2 m on the data stated above. and to Me bolt of my knowledge. From Cho causes stated. <br />g 22s 1IONA Y yyret, o. rylr) 22L ADDRESS 1124 W. Third DATE SIGNED <br />6oYdb �'. I'Yr2t i's( Pt.If. `rand Island, V�raska 7/7/67 <br />V <br />V 23o BURIAL CREMATION. M DATE 23t NAME OF CEMETERY OR CREMATORY 231 LOCATION (Cd /, town. of county) (31'sftl <br />1y b21967_1 Grand Island Cemetery Grand Island Nebr <br />'�'I31�3Y Ju_ - - -- - - - -- <br />21. DAY{ RECD BY AfGISTRAP 12S. REGISTRAR 5 SIGNATURE 26 . NAME OF MORTUARY A RESS <br />Apfel- Butler- Geddes; Grand eland, Nebr <br />i <br />Issued July 20/ 1967 <br />