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a LOCAL PILS "W"AlR
<br />1. DECEASE
<br />4e, AO/ I I n
<br />Lest alit
<br />54
<br />1.363
<br />FIRST
<br />DON R
<br />or Townthlp)
<br />Section of Vita( Statlstlts 2 0 0 312 7,,415' CERTIFICATE OF DEATH STAYS FILE NUM /ER
<br />MIDDLE LAST 2. SEX 2. DATE OF DEATH Me. Day Year
<br />ABERNETHY MALE I NOVEMBER 19 1980
<br />DATE OF BIRTH Mo. D•v Peer a. RACE (So-fly) t.. COUNTY OF DEATH
<br />Janus 14 1926 Caucasian Olmsted
<br />7c. Inside Corporate 7d. HOSPITAL OR OTHER INSTITUTION - Neese 11' not in ef~' Give Strom
<br />LI_It t seif end Nv~i
<br />Rochester 5
<br />e p Y
<br />Ste Marys Hospital
<br />/. BIRTNKACE ( /tats M Parolgn Country)
<br />S. Cltlton of What Ceunlry 1
<br />Divorced (8o"Ifv)
<br />11. SPOUSE - NAME
<br />Wyoming U
<br />U.S.A. M
<br />110.Mal,led.No.Olk4o,,Id.Wido--d, 1
<br />Irene (
<br />(Auble Abernethy
<br />12.NIse Oweeased evor In U.S. Armed 1
<br />12. SOCIAL SECURITY N
<br />NUMBER 1
<br />1N. USUAL OCCUPATION (Give kind of work dur 1
<br />14b. KIND OF BUSINESS OR INOUSTRy
<br />FeroN (SpecNY Yes or Mel I
<br />505 -20 -3089 D
<br />Doctor O
<br />Optometil
<br />15 c
<br />1M. RESID -STATE 115b. COUNTY
<br />Limits - Spool /y
<br />Nebraska Hall Grand Island ft YES ONO
<br />16o. FATHER - NAME 16b. BIRTHPLACE (Stets or Foreign 17. ADDRESS OF DECEDENT Street end Number ►oat O ke
<br />Country)
<br />Verne Abernethy Nebraska 707 Se Blaine St. Grand Island NZ 6880:
<br />1M. MOTHER - MAIDEN NAME Mo. SIR HP LACE (State or Foreign 16. INFORMANT- NAME Addreas
<br />Country)
<br />Helen Ans ach I-eMe Nebraska Mao Clinic Records Rochester ME 5590
<br />20. PART 1 _DEATH WAS CAUSED By (Enter only one cause per line (A1, (B) end ICI I IF DIAGNOSIS DEFERRED Approximote Inservel
<br />cn «k Bo. Betw•an onset end Oeedt
<br />A. IMMEDIATE CAUSE
<br />Coronary atherosclerosis and insufficiency
<br />t. DUE TO, OR At A
<br />CONSEOUENCEOF
<br />C. DUE TO. OR AS A
<br />CONSEOUENCEOF
<br />TART 11 - OTHER SIGNIFICANT CONDITIONS 21o. AUTOPSY 121b. It yes, we tlndlnse a"-
<br />= Specify sldered In detarmining cause of
<br />PESO NO do.,,, Yes
<br />H
<br />< 22a. ACCIDENT, SUICIDE, HOMICIDE OR UNDETERMINED 72b, DATE OF INJURY Mo. Day veer I Hour 22c. INJURY AT WORK tpeeHy Yse er Ns
<br />V IF DEFERRED
<br />W Ch k o
<br />i' 22d. PLACE OF INJURY (At Nom•, Fsem, Street, Factory, Office Bldg. Etc.) 22•. LOCATION Street or RFD N.-h- City, Village or Town•hlp County Stem
<br />Q
<br />W
<br />V
<br />J 2211. NOW INJURY OCCURRED IEnter Nature of Inlury In P•rt I or Pert 11, Item 20)
<br />U_
<br />p 22e. CERTIFICATION - PHSjCy/�/lt /�k1o. Day YN, 11 Pi R•�8(,•ar 22b CERTIFICATION - MEDICAL EXAMINER OR CORONER
<br />W!
<br />Is ttended the deceased from IT M1860.
<br />1j �� 11 to �`j� / 88 ""and on the hash of the examination of the body and /or the investigation. In my opinion dense
<br />11 ! (� Year
<br />foot sever himn. NM on M/o 19 / Q9b . I Idld, din not) view the body after death occurred at M, on the date and due to the causes stated abort. TM decedent
<br />� �/��'p Mo Dar Year
<br />Death oeLVwed J :04P M of the plan and time and on the date stated above and to teat pronounced dead on m M.
<br />the beat of my knowledge due to the causes stated.
<br />231e. PHYSICIAN - SIGNATURE i i4l 11 123d, MEDICAL EXAMINER OR CORONER - SIGNATURE
<br />236. PHYSICIAN - NAM (Type or Print) 23f. MEDICAL EXAMINER OR CORONER - NAME (Type or hint)
<br />J. Lu&ig, . De r
<br />206. MAILING ADDRESS Physician, Medical E-min•r or Coroner 23h. DATE SIGNED
<br />MenM Dey Yee.
<br />In For the May Clinic Rochester, MN 55901
<br />24. BURIAL, CREMATION, REMOVAL 24b. CEMETERY OR CREMATORY - NAME 24c. LOCATION (City, Vill." o County) (State)
<br />t°"'" , onoua sand J-,A md, 1t e6�a
<br />24d. DATE OF BURIAL, CREMATION S. FUNERAL NOME a- 71Nnnme 1�nit } 25h FUCFj��ERAL�1{,COM_E }- Add
<br />.ew
<br />REMOVAL Mo. Day
<br />Year ,a/1 /1_Q/.i/ l,Qi'1JrlvC� V !IIN 1/lr'11('IJiA( JU�i t,Q'.YI�QIL, IIVfk•
<br />2N. DATE FILED By LOCAL REGISTRAR 26b. L AL REGISTRAR Ignat�.• `^"_ - `F1 27 M ICI R FUNERAL ECSQR - Signature
<br />y1q. Year
<br />I
<br />A
<br />Coronary atherosclerosis and insufficiency
<br />t. DUE TO, OR At A
<br />CONSEOUENCEOF
<br />C. DUE TO. OR AS A
<br />CONSEOUENCEOF
<br />TART 11 - OTHER SIGNIFICANT CONDITIONS 21o. AUTOPSY 121b. It yes, we tlndlnse a"-
<br />= Specify sldered In detarmining cause of
<br />PESO NO do.,,, Yes
<br />H
<br />< 22a. ACCIDENT, SUICIDE, HOMICIDE OR UNDETERMINED 72b, DATE OF INJURY Mo. Day veer I Hour 22c. INJURY AT WORK tpeeHy Yse er Ns
<br />V IF DEFERRED
<br />W Ch k o
<br />i' 22d. PLACE OF INJURY (At Nom•, Fsem, Street, Factory, Office Bldg. Etc.) 22•. LOCATION Street or RFD N.-h- City, Village or Town•hlp County Stem
<br />Q
<br />W
<br />V
<br />J 2211. NOW INJURY OCCURRED IEnter Nature of Inlury In P•rt I or Pert 11, Item 20)
<br />U_
<br />p 22e. CERTIFICATION - PHSjCy/�/lt /�k1o. Day YN, 11 Pi R•�8(,•ar 22b CERTIFICATION - MEDICAL EXAMINER OR CORONER
<br />W!
<br />Is ttended the deceased from IT M1860.
<br />1j �� 11 to �`j� / 88 ""and on the hash of the examination of the body and /or the investigation. In my opinion dense
<br />11 ! (� Year
<br />foot sever himn. NM on M/o 19 / Q9b . I Idld, din not) view the body after death occurred at M, on the date and due to the causes stated abort. TM decedent
<br />� �/��'p Mo Dar Year
<br />Death oeLVwed J :04P M of the plan and time and on the date stated above and to teat pronounced dead on m M.
<br />the beat of my knowledge due to the causes stated.
<br />231e. PHYSICIAN - SIGNATURE i i4l 11 123d, MEDICAL EXAMINER OR CORONER - SIGNATURE
<br />236. PHYSICIAN - NAM (Type or Print) 23f. MEDICAL EXAMINER OR CORONER - NAME (Type or hint)
<br />J. Lu&ig, . De r
<br />206. MAILING ADDRESS Physician, Medical E-min•r or Coroner 23h. DATE SIGNED
<br />MenM Dey Yee.
<br />In For the May Clinic Rochester, MN 55901
<br />24. BURIAL, CREMATION, REMOVAL 24b. CEMETERY OR CREMATORY - NAME 24c. LOCATION (City, Vill." o County) (State)
<br />t°"'" , onoua sand J-,A md, 1t e6�a
<br />24d. DATE OF BURIAL, CREMATION S. FUNERAL NOME a- 71Nnnme 1�nit } 25h FUCFj��ERAL�1{,COM_E }- Add
<br />.ew
<br />REMOVAL Mo. Day
<br />Year ,a/1 /1_Q/.i/ l,Qi'1JrlvC� V !IIN 1/lr'11('IJiA( JU�i t,Q'.YI�QIL, IIVfk•
<br />2N. DATE FILED By LOCAL REGISTRAR 26b. L AL REGISTRAR Ignat�.• `^"_ - `F1 27 M ICI R FUNERAL ECSQR - Signature
<br />y1q. Year
<br />I
<br />A
<br />236. PHYSICIAN - NAM (Type or Print) 23f. MEDICAL EXAMINER OR CORONER - NAME (Type or hint)
<br />J. Lu&ig, . De r
<br />206. MAILING ADDRESS Physician, Medical E-min•r or Coroner 23h. DATE SIGNED
<br />MenM Dey Yee.
<br />In For the May Clinic Rochester, MN 55901
<br />24. BURIAL, CREMATION, REMOVAL 24b. CEMETERY OR CREMATORY - NAME 24c. LOCATION (City, Vill." o County) (State)
<br />t°"'" , onoua sand J-,A md, 1t e6�a
<br />24d. DATE OF BURIAL, CREMATION S. FUNERAL NOME a- 71Nnnme 1�nit } 25h FUCFj��ERAL�1{,COM_E }- Add
<br />.ew
<br />REMOVAL Mo. Day
<br />Year ,a/1 /1_Q/.i/ l,Qi'1JrlvC� V !IIN 1/lr'11('IJiA( JU�i t,Q'.YI�QIL, IIVfk•
<br />2N. DATE FILED By LOCAL REGISTRAR 26b. L AL REGISTRAR Ignat�.• `^"_ - `F1 27 M ICI R FUNERAL ECSQR - Signature
<br />y1q. Year
<br />I
<br />A
<br />
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