|
I
<br />t
<br />STATE OF NENIASKA- DEPARTMENT OF HEALTH
<br />BUREAU IF VITAL STATISTICS
<br />_ CERTIFICATE OF DEATH - , , i - 00630%+
<br />►IR MI Dl� L. IIN., Day. Yr.)
<br />OEC N -N r,PAT_ /YaQd1,11 e,,.. L c. DA E Of DEATH (A-
<br />1T . � loia 17 LCC01nL,C1_ .t7, LVOJ
<br />RACE -N/. WAiq, /LcA, ARralitM ORIGINJDESCEN ((a /_11.Ii..,EMcic.n, AOE -4x RinSdry UNDEf_I YEAR?_UNDER I DAY DATE OF BIRTH (M. „DRy,YF.j
<br />IMw•. aR.)(S '1T) Oars.., .Ic 1(SOad/y) 1 (Tn.) MOS. DAYS MOORS • MINS.
<br />A. l�hite American �6 �;
<br />CL A wtE G /NTH lM .wF rw rJ.S.A.,
<br />.a•rR cw.N,)
<br />w. Z6 Y February 26i 1907
<br />CITIEE.. OF WHAT COUNTRY MARRIED, NEVER MARRIED, NAME OF SPOUSE f1 /.rH, prn r «4...Ara1
<br />•. Polk, Nebraska
<br />WIDOWED, DIVORCED(Specify)
<br />p U.S.A. ID. Married ,IGeor a McMullen
<br />SOCIAL SECURITY FN/M/ER USUAL OCCWATION(Giq liM af. «1 d•na d•ri.p .1•N KING Of BUSINESS OR INDUSTRY COUNTY OF DFATH
<br />a/.a.Ai.p Ei4, ann it nlirad)
<br />Iz 06 -62 -20 4 Is..
<br />Housewife 17b, Own Home Id.. Hall
<br />CITY, TOWN Ot IOCAT1pN OF DEATH
<br />INSIDE CITY LIMITS HOSPITAL 01 OTHER INSTITUTION- Noma(If.os,. airA«, Ir rTOf► WrNf7 M /Irr•DOA.
<br />kei. BOA'
<br />114b. Wood River
<br />;SPacil, YQE«Na) piw Th•N.w/.vnrb•r1 li•,MN•M /[.•r M. rdyE
<br />,.E. Yes Idd. Good Samaritan Center ,d.. Inpatient
<br />MSIOENCE -STALE COUNTY
<br />I
<br />CRY, TOWN OR LOCATION STREET AND NUMBER INSIOl CITY LIMITS
<br />is.. Nebraska 151. Hall
<br />,sYGrand Island Isd.1319 N. Park (sn «.yY „ «N.)
<br />Sp-f” -
<br />A I
<br />MI 11Sa.
<br />-41 UECEASED EVER IN U.S. ARMED FORCES? iINFORMANT- NAME�-
<br />-NAME
<br />Grace
<br />ETIONSHM- MAILING ADDRESS (flHl
<br />len- Husband- .1312 N. Pf
<br />- NAME LOCATION
<br />Q ADDRESS ISTQ @T DE R F D NO. Cm
<br />Hulbert
<br />F D NO. CITY W TOWN. W
<br />-'I- w_ KOeM ; Grand Is1EEPd, N
<br />YE OE Ain (AM., DaY, Tr.) DA1E SIGNED IMQ Do), Yr) HOUR OF DEATH
<br />DATE IGNEO (Ma., D I. Yr 1 MOUE OF DEAIN -- _
<br />r, i ItONOUNCFO OFAD ERONM10EC wt
<br />IIMo . Day. Yr) - i -- - -- DEAD (Neurl
<br />c• r•• bM •i M L.•. •dQ•. d \ ..•d .. rM w.y. 4w d PI«. and dr. r. rM e 2 O — �.11!� _ M
<br />� � ..•dl .raM � w � a O V (Ow M. lrr. N N•�w,wanew •n►I« .. r1Ear,•w. •n .r •Frnr•n d•aM «rrr,./ N
<br />e I .M r.y der. awe PI «..M dr• Y M. r•rMlx .VMd
<br />i Esd Esy....r• .w r.w, r l.i /ldbl... �{- _CI4�T.L /_L 11 I T.. If•.w «r.. eM r•A., ►
<br />NAME AND ADDRESS OF CEf(T(PNYSICIAN. CORONER S PHYSIC AN OR CO TY ittOQNEY) r T
<br />ss Dr. Sheridan Anderson 1811 2r.d — rand - IslElnd tlr 6£PG
<br />. 1
<br />_DATE RECEIVED BYRE(:ISTRAR IM Ooy. rr, '-
<br />i
<br />Z7. 611E11IE04TE CAUSE r (ENTER ONFY ONE CAUSE FER FENS TOR (P/, (b), AND fell
<br />IAR I
<br />DUE t0. 5F AI w CONSEQUENCE OE. - - - -- - - -- -
<br />-
<br />M
<br />DUE 10, Of AS • CONSEOUENCE
<br />w
<br />►yT�Er.tR •N CDNaT,ONS- Cwd.w..ru• ►ru,y y�yM w.w «. —.ruyd . pnl iE rE/YEe -5 ,Ne @• -- AAulorsl -- -- w,�S_U3l �EiLBRfD fo;1eae•E
<br />R I PQEGNANCY IN IHI PAST) MONTHST ; I Sq.•E. r N.l CSX rx ER CR CORDPrER
<br />KIDfM. fUKrOE. rN7wC10E. Y!.pl DA71 of M,uaT l•y.. a.. ,, ,— i Houi a Iwu.. I oES� QE npw lyir u�r pCCVMED _—
<br />OR PEE.arw xe.eslpATMoe 15” 4r)
<br />S/.. 06
<br />MIUH AT .61111 1 FFACE d M,URY _ •� M•.•. 1.— n.- .'rr «i. rm M 70c oc�1 0l+ �a -- -- . -
<br />15"d, Ise . W, II Nrr.• Rr•Idrrra. .w /SP«A,l S1NEl W Pr D M _ - -CIT OQ tOMM
<br />so.
<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 />V I T�LR>:C,ORDs.
<br />AS IS AN D Issued December 27,' 19$3
<br />F EAL H LINCOLN, NEBRASKA
<br />a
<br />01
<br />I
<br />io
<br />i
<br />
|