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IN
<br />STATE Of IEMASKA- DEPARTMENT OF HEALTH
<br />WNEAU"VITAL STATISTICS 3
<br />86- 104112 CERTIFICATE OF DEATH,,
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<br />4CE -h.{., wbae, W.1, AA.NSa TOMGIN "DESCENT -. q , Noflon. W ko AGE UNCfR TEAR JHJER t GAY DATE Of tIRtM fro D , rr ;
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<br />.- -__.__- !`. .......__ d` NAME Of SEOUSf (If f y, +e mo�d.n nen.l .__.___
<br />AND TAit OF {1RTM (M w.G in U S A, (CITIxEN OE WMA7 COUNIgY:MARCE.r. NfYFt MAggl£D.
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<br />M S�iAI OCCUPATION (G' +. F.wd ol�orF do edrrrlwgwr IRIND OF {U5INESS OR1ND115TRY COUNTY Of DEATH
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<br />H510fNCE -STATE COUNTY jC1T•, TOWN OR LOCATION rSTREfT AND NUM {E■ IN51CF tYt HITS
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<br />'fAH -NAM EIR3 - -- MIDDLE __.UST ____ ___
<br />1 MOTHER MAIDEN NAME FIRST MIDDLE IA�T
<br />,• Gustave er> rae
<br />WAS OKEASLO EVER IN U.S AlMfD GOKESF INFORMANT -NAME -- RELATIONSHIP - MAILING ADDRESS 15nEFT 01 R r D NO. t1r'r 01 IUwN SfAfE ZI.?
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<br />~ {VRI ►l, Crewlion, Rewvol AT CEMETERT GR CREMATOIY -NAM[ r:OG7tON CITY OR TOWN 37Aif
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<br />DATE OF DEATH (M.- D;Y" Yf I I DATE SIGNED (MO. D." T. MOOR Of DEATH
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<br />xx. : ]. 3/0/43 x.b 5.30 a.M
<br />t DATE SIGNED (MO.. DoY -Yfl iHOVR Of DEAfM pRONOUI�NCF�DI DE[AlD vgONOJ/NCED (D�EAGIN 1 a.
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<br />NAME AND ADDRESS Of CEgitNFg (PHYSICIAN. C:•aoNE Pw T51GAN Ot COUNTY ATTORNEY; flyp, o. p-r) - �-
<br />xs. Stephen L. Von Ftie4e11 _ i_ 1 __ �tcri, , ?. sn, LCL, 'r -, j ia
<br />gEGIST DATE SE.CHVED BY REGISTRAR ?M. D r
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE ABOVE 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 />DIRECTOR, BUREAU O? VITAL STATISTICS LINCOLN, NEBRASKA
<br />Sc, tsar ly Fif ty(5 %) 'Feet of Fractional. l,et
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<br />Cour•ty, :ebraska, anti its 'or,lnl.ei�le;;t, tr, -wi.t: Fractional.
<br />Lrot Four. (4) , in Fractional i :locl. One Euri,lic,l ;:r is0 < }),
<br />ic: ar,: t",i.ei :ms's Addition t: tire:
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