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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE N BRASK102333 <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 [�Ij *4-- � <���N / <br />APR 2 3 19988 STANLEY S. COOPER, DIRECTOR <br />LINCOLN, NEBRASKA BUREAU OF VITAL STATISTICS <br />Pas-Ttt(vq Rsv. PUBLIC dTATZ OF N�1[A81CA 57-009535 <br />EDUCATION OP PUBLIC HEAL?■. DZPA$T1dNT OF HEALTH <br />EDUCATION AND 1►lLTAR! <br />Oala■■ or Vtt■l sl■tieum <br />BIRTH No. 126........ CERTIFICATE <br />OF DEATH STATE FILE No._ <br />I. PLACE OF DRATM F. f. 5 o <br />a. COQ Hall <br />l re tetien, ,ayd,aw <br />'' FATE Nebr 1~ GovNTx al hdere .a.w.g). <br />L CRT (It evidde wrilwaM Milts, write Rural) <br />e: L! N 0 T ■ OF <br />a. CITY (It etlaUe @04144 t41 HI.Bs, writs RURAL) <br />TOWN Grand t.land. <br />a- <br />4TN Grand Island. <br />0. PULL NAYS OF fit sot In heWt er tnetitetlen, sip street <br />Franois Hospital ) <br />a. STREET <br />2120 ne(sf t �aar.W . en) <br />ADDRESS <br />s. NAYS OF a. (First) b. (UMN5 a. DATE (Ya�lk) (Day) (Year) <br />DECEASED <br />.r Mat Q s Cis Yearn DEATH Sep Tie <br />21. 1957 <br />L SEZ L COLOR er RAC! <br />T•. MARRIED, NEVER MARRIED. <br />L DATE OF BIRTH f. AGE (In yr.. <br />!t Vaaw I Yr. [t Undw it Hre, <br />Dale 1�hite <br />vvoRCm cssetity) <br />loot. 9. 1603!" b) <br />)`°Y Hoare MI. <br />Tae. USUAL OCCUPATION (Give kind of work lah. <br />darlas awl si worklatt Hie. even It retired) <br />>QIJD OF BUSINESS 11. BIRTH- (CII tgewoarel— oeeaeapb�c)r�(B�ab 12, (�,7pTUIyNTg1 OF gHA•I, <br />CITIZEN <br />OR INDUSTRY PLACE <br />RYT <br />jj <br />Red Ci�OUQ +'Ie 0)r <br />IL FATHER'S N ! lea. MOTHER'S YAIDIN NAME <br />14L NAME OF HUSBAND Olt WIFE <br />Charles E Fearn Uartha Newhouse <br />Nertle Yearn <br />Ii. WAS DECEASED <br />( Yea6 w6 er enkarwg <br />EVER <br />(If <br />IN U. S. ARMED F(,-r=ST It. SOCIAL BECURRT 37. INPORMANrS NAME or Signature ! Addrew <br />yee. give war er daW of Service) O <br />-Y ' <br />06-09. -675 i.�t "yearn, Grand Island <br />MEDWAL CZBTmcATxoN atervaa brown <br />L <br />O7- <br />Is. CAUSE OF DEATH <br />Eats only one aaw vet <br />Hen for (a). (k). as/ (e) <br />DISEASE L LADING O , and Death <br />DIRECTLY LICADING TO DEATH //�t� ✓✓ ��,, <br />'Thfa Mr net w.aa tN <br />AtdTECEDETT CAUSES <br />! amwe of <br />DUE DUE TO (► - <br />1 e4. It moms Ike dY- <br />-.- <br />YMId heabove c it aa) at.lag - -- <br />can" ebting <br />i sew. IaNry. w ewtrMta- <br />Um whir! neetd death. <br />u`�. a1aM�rblweet y <br />DUE TO (c _.. _.._ .........._ .�___,,. <br />- _._.._a_....y_._.. <br />IL OTHER SIGNIFICANT CONDITSON9 <br />O1 <br />CenaHNwe — 1,1bud- In the death but net <br />I <br />relaW Ie tM afwew er e.aaltlea eawlaa Math. <br />1ta. DATE OF OPERA- <br />TIONI <br />IM MAJOR FINDINGS OF OPERATION I <br />zo. AUTOPSY? <br />• <br />Yw � Ne� <br />21a. ACCIDENT (Sp.lfy) <br />SUICIDE hose. <br />231. PLACE OF INJURY (e.m. In or abet <br />fares, factory, street, office I�Ida., eta) <br />21c. (CITY OR TOWN) (COUNTY) (STATE) <br />(If Ter d area, write RURAL) <br />HOMICIDE <br />21& TINS (Month) (Day) (Year) (Hoar) <br />1 21WhII. nt Work <br />21f. HOW DID INJURY OCCUR? <br />INJURY M. <br />Not While at Work O <br />1 22. I hereby certily.4hat I <br />E�td alive <br />211 iA1'URE r u/ <br />VP Bye <br />ded the deceased <br />al` = and that death occurred <br />i-�— sre�1� DD <br />tT 2ta NAME OF CEMET Y OR C1I <br />4 574 57 Gr�I 1 Cemetel Cemete <br />II �� 25 n�_ 2S n <br />0 <br />o0I 19t' 7 that I last saw the do- <br />le causepapd on the date stated above. <br />f 29CDATE SIGNED <br />-75 -1'! <br />Nd. LOCATION Mm town, or county) ( ) <br />Grand Island. Nebr. <br />M..'S SIGN ADDR <br />I <br />a•�i <br />j'CD <br />