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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE <br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COPY <br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT OF HEALTH <br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY FOR <br />VITAL RECORDS. <br />DATE OF ISSUANCE <br />MAR 2 g M] STANLEY S. COOPER, DIRECTOR <br />LINCOLN, NEBRASKA -)BU EAf}IOF,VITAL STATISTICS <br />MEMO' <br />-- 101979 <br />Pww STATE OF NEBRASKA <br />). PD.ACB Or DRA771 <br />Department of Ilealih- Dirision of Vital Statistics M ae/ write is std. spsm <br />� CERTIFICATE OF DEATH 4, 7(T/5 <br />Gnat, - f8�.,�- ,- �- ., <br />a` `�- - - - - -- <br />Township _ s;% Qu - -- <br />Lush of toddsace In city or tom where death msemttcd..._sr.� mo• <br />L FULL NAME___- J1JJLUaM !'. ry <br />-k�i <br />POUM44AL AND STATISTICAL PARTICULARS <br />L SEX t. COLOR or RACE 6. SINGLE (Sank• the word) <br />Married <br />Hale White � n � Harried <br />ia. If sarr" widewor or diearnd <br />UUSBAND of <br />or <br />WIrR of Marie Pahll t [f <br />g. DATE or Blare gars.) Clot. (a.,) 24 (rear1903 <br />7. <br />Age Yew* eis s Months Days if l than 1 day <br />36 I 9 5 In ------ or Min.-- - <br />L Trade, pefeaslew or partlerlar <br />s tend or w.ek dstu. as .data'_ <br />O Sawyer. baofkeow'. <br />r* p. W.643y •r bw Sab <br />,wee I les <br />work wen does vtal� Grand Island - <br />Sate MI1L boob. ate. .t__- -________._ -- ----- <br />1p. Date dtsoassd test yw•rrlmd� tat 11. Total time (sears) <br />1 sv) �ri– >lf'rJ -d- � nib 1s- .�,i -- ^•— <br />City or Towm__acv ±a &_ -- _Mw <br />14. Blrtivlsaa State Cenah_- �DY.wlila��2 -__— <br />M Name at Felber___ <br />N. Birthplace City � own <br />of <br />rather state i6. Mddm Wages of M•thor— japook, { a Ott y _ <br />is. Birthplace City or Town <br />of M Stan cad Comah__le-Tr__ °kas —__ <br />17. 114FORKATI(M ?' _= ii- li,a�.,PA_b_l_,L — <br />is UNDERTAKER - ivy <br />(Address) �rjsnl <br />w. FttN>�(i•�9i 1�JF/} �>� �G- = :.- e- .�emrrr <br />-- i0121- 'tih - -_4111 aea:h .«a ale it NAME <br />rt.d to a howsal <br />i laatitmtlon <br />nstead of stroot end .member. <br />Bow tome In V. S. it of foreign ►!rtb__.ye. ids. <br />-- MEDICAL CERTIFICATE OF DEATR <br />A. DATE Or DEATH_ -_ -__ » <br />21. I HEREBY CERTIFY. That at doemoud few <br />— t:�1�L. ts� ta�`� -- 10-D <br />I tut • b___ alias ea_____ is -_. �v add <br />to here eeturred on the dais stated abeee. at___ rJR.► -Y. <br />The prinetmel thaw of death and related tame of 1 wetaaoe Is <br />order of ouet wore v follows: <br />D.a er Davis <br />Contributory cause of Imperteate met related to Wmtlpttt adm�� <br />" 1 <br />N-1tar of aWatioa — --------- _ -_Dsto <br />rRQiat tat e-firtaed dtaanoshT ---- was ihsrr an sutspayT____ <br />!s. If destb wu doe to ext end wins jelanea) all In also the <br />following: aJGIANt.FtA <br />AeNdant, suicide. or k•®1�{daT��u of l uV �. 1L�� <br />Where, did Imlur7 occurt <br />y w Sash a sty. sad tats <br />Specify whether I1!ju ote +�}gdutt , i ma. ot,Ia pmb- <br />lie date. !;• �� (th'A <br />Mamser of :.fury ---I� <br />Nhtwm of Shinn_ <br />U. was d:sras• er Injury In w way rolm.tod to r, u,! .y tleaaa1 <br />deceased? �U■_� i (( -t.- <br />If se. meelf'.. _ t -- --- _ - -.-- <br />01 <br />i <br />