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<br />CERTIFICATE Of DEATH- ( ~~
<br />Df CIDINi-MAM itf3i -V-DIE U3~ -'~Ei -~ ~ `DATE OF DEATH (Me. Da,, Yr.)
<br />Ted Frederick z.Male
<br />i. Tv >. August 22, 1960
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<br />I~pATE OF fIRTN(MO., DvY. Y..I
<br />fACf-Try.. wbNe.Rla<1, Amrr:ro+:ORrG!NiDFSCENt!e.y,l•elean, M..~<an,i'GE-ie+•+:nedev UNOER'YEAq UNDER
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<br />.. w!:ite Is unknown ~'-I ~ae 49 ab. ~ ~ar.~7JaruarV 9. 1937
<br />CITY AND STATE Oi RIfTH Irl nol .n U 3 • , CITIZEN OF WHAT COV NTPY MARRIED. NEVER MARffED. ~ NAME Of SPOV SE{t/~~/e. p~.e m~ nom.)
<br />nemr rev N 1 I ~WIDOwfB, DIVOKED(Tpr.~l,)
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<br />Rnckville,NE ~a L'.S.A. ilo A3arried
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<br />KINC OF fUSINE55 Gq INDUSTgY COUNTY OF DEATH
<br />SOCIaI SECURITY NUM¢Ft USUAI OCCUPATION(Gi.r S:nd eE~er[deer during moat
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<br />Ipi.e.E;ng b/....rn H..r;r.a) Tavern owner
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<br />Ez. SOS 40 0079 ue C erator of a Bar i
<br />CITY,TOWN O4 LOCATEON OF DEATH INSIDE CITY LIMITS HOSPITAL OR OTHER INSTITUTION-Nome (1!ne•in eirber, III NOSP OE IHSi Ind:wer DOA.
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<br />fESIDENCE-STATE CGUNIY CITY,TOWN Oq LOCALION STREET AND HUMBER INSID~CT'IIMIT
<br /> (Spw'i, Yrr or No
<br />TseNebraska ,sb Hall Isr. Cair ua uf.
<br />FATNEf-NAME iIRTT MIDD[E UST iMOTNER-,MIDEN NAME FIRST MIDDIE USl
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<br />Fred~_ri~k ~ 17 (Dec.) RosQ ~I;NKN) Pni nknwcki
<br />la Dec. Tony ~U h~+~)
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<br />WAS DECEASED EVE! IN U 3 •¢MED FOPC ES? ORMANT- NAMI-R[LATIGh'T NIP- MAILING Ap0RE13 !SIrEn 01 .,.D NO.. Cltt Of fOwN. SiAlf. Iltl
<br />`,j(es/Ro~!6-1848/6-13-52 ~,pMrs. Rosalie Frederick-wife, Box 35, Cairo, NE 68824
<br />BURIAL, [remotion, Remeral~DATE ICEMETFPV OOR CREMA104Y-NAME ~LOCAiION CITY OR TOWN STATE
<br />we. Burial i7ob8-25-80 xv)It Calvar Cemetery zoa. Ravenna, Nebraska
<br />EMa FR TURf 6 [ECENSf NO FUNE0.Al HOMf-NAME AND ADDRESS ISTleti 01 E F D HO, Citt Of TOwN, STArl. 21x1 -
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<br />y~`~' ove 6 Rohde-P.OrBox 73-Ravenna, NEB 68869
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<br />, 01, Y - O 4 OF DEwT Y r ~ A I N D (MO. Do,, Yr.) ~ U
<br />° DaiE SIGNED !Me
<br />~.dl,]bAugust 26, 1980 17]r
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<br />E s DATE OF DUTH (Ab.. DvY, Y<.) 1 ap0 ogONOUNCEO DEAD ~PgONOUNCED DEAD(Heer)
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<br />z]d. August 22, 1980 z.a.
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<br />NAME AND ADDRESS OF CERLIi1EP (PHYSICIAN. CO0.0NE¢'S PHYSICIAN OR COUNTY AITDRNEY) (lipe er Pr~n,)
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<br />37. IMMEDIATE CAUSE j' (ENTER ONLY ONE CAUSE PFR LINE FOR ja), (bJ, AND ;<)) nnn°I b«.rw w+« and dwrb
<br />PART ,
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<br />Acute myocardial infarction 1 hr
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<br />i DUE TO, Oq AS A CONSEQUENCE OF: nHmel b....w °n+« °nd dwtb
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<br />Da Arteriosclerotic heart disease yrs
<br />DUE TO, OR AS A CONSEQUENCE OF: Hnol b.t..rn on.« °nd dwM
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<br />PART THEI SIGNIHCAHI COHDrtIOHi-Cn..d~l:.n. •wn:b.+'np <dw+b b.l n« ..loved j fG 1 rtIM4„, wAS THtpE w ! AUlOPS1 wzA3 C'3, Ef.EEEfO SO MFgCAI
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<br />I EPASIJwONTH3T ~ES°...Ir I««N°) AM dCO,OHER
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<br />ACGDEMi. SUIC~tt rOrJCiD(. UNpti _ r( O( IwIUfY («.- D.,, .. ul O. I.UU[. _SC eIS_ YOw w)u[I OCCU[lE0
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<br />Ai wpf[ uCt O,ir.,;.PY ..., 1°.... ...w< I°r+ ~. UiION STltfl O. [ i.p H. [ITT Ol iOwH STATE
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<br />WREN T~AIS C PY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />STAp'E DE•PAR~MENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br />A~,T UE COPY OF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />DEPARTMENT OF AEALTA, BUREAU OF VITAL STATISTICS, WHICH
<br />IS TAE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DIRECTOR OF VITAL STATISTICS AND ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA issued September 3, 1980
<br />DESCRIPTION: W100' Lot-'S o oc
<br />Town of Cairo, Hall County, Nebraska
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