|
~^y y STATE Of NEBRASitA-OEAARTfIREiiT Os HEALTH
<br />P 7~~~8~~~~tr 5 BUREAU Of ViTAI STATISTICS
<br />~.7 ! al ~f~TiF16ATf OF DfAT~I ~ _ , t,~~
<br />
<br />DET- (.Q,RENT-NAME FIRST MIDDLE LAST ~~ SEX DATE Of DEATH (Me, Doi, Yr )
<br />'
<br />t 1 '/-tl1GG~.~Q SCeG~tBYCYt z. ell ,~_ ]. ~O-a 1QT'!Q~ ,^
<br />_.s~q...~
<br />F~Q
<br />AOE wU n:nwn
<br />CINDER I YEAR UNDER , D DATE OF &IRTK IMa
<br />Yr
<br />7
<br />h lion
<br />Ma.kan
<br />Da
<br />~
<br />DESCENTi
<br />e
<br />OWIGIN
<br />Wii
<br />L
<br />A
<br />~~'
<br />t-=
<br />(5
<br />.
<br />,
<br />,
<br />r
<br />.,
<br />R.,
<br />msr
<br /><on
<br />(
<br />ru
<br />.
<br />Y.
<br />Cf-fe.R., w
<br />a,
<br />RA
<br />Indien„ew !/~T„_ ifY) p«i!y) (Yn.) MOS. DAYS HOURS i MINf.
<br />1- ~1
<br />t
<br />•
<br />12
<br />!
<br />~
<br />]
<br />K
<br />A
<br />I
<br />a,.
<br />1
<br />1
<br />rtIP1LCCLUt
<br /><. U(F
<br />l4
<br />~
<br />L
<br />ab. a. ~
<br />z Atte. 18
<br />190^,_
<br />s.
<br />CITY AND STATE OF 61RTK !H ne! in U.S.A., ~
<br />CA12EN Of WHAT COUNTRY MARRIED, NEVER HURRIED, NAME OF SPOUSE (II:iTe, Riva moidan me)
<br />eeme ~enhY)
<br />Neb
<br />d
<br />k orooWEDe~ (spaa:%r)
<br />U
<br />$
<br />A
<br />St
<br />R
<br />OO
<br />asa
<br />Q „
<br />e
<br />.
<br />a
<br />.
<br />P.
<br />eG~I~ff2Yt
<br />SOCIAL SECURITY NUMBER USUA! OCCUPATION (Gin Li.rd of wort done during more RIND OF BUSINESS OR INDUSTRY COUNTY OF OFATH
<br />
<br />50
<br />24
<br />46
<br />3 of wortirp 1i6, mn i(.eH.ed1
<br />~
<br />,:,
<br />7-
<br />-
<br />6 ,,,
<br />,ab. ue.
<br />Sr
<br />IW.a~
<br />ROA
<br />CITY,TOWN OR LOCATION Of OEATN INS,OE ITV lIM1T5 NOSNTAI OR OTHER INSTITUTION-Noma (IE n°r in either, I~NO
<br />w IwST
<br />Va*
<br />M
<br />n
<br />~-~/
<br />.
<br />i Tip«iYr rat or ND/ pin anaer a d number!
<br />d I
<br />l
<br />d
<br />t~
<br />c
<br />y
<br />L
<br />U
<br />Raec
<br />,Ae.
<br />a
<br />ax
<br />,k.
<br />ea ,Ad.
<br />„b_
<br />u
<br />ieRan I
<br />RESIDENCE-STATE COUNTY (CITY, TOWN OR LOCATION STREET ANO NUMBER INSIDE CITY !INKS
<br />f5p«i!y Yea « Ne)
<br />Ne6~aakE: ,sb NaU ,s< Ci~tand Iatcuid Isd 14 N tacua
<br />t j,s
<br />i
<br />y¢e
<br />e
<br />,s
<br />.
<br />~TAaN R- AME iR w MI LAST ~ MOTKER-AUIDFN NAMC i1RST MIDOL lA
<br />~,,,. €Aed ---- ~eewce. l iT M_98~-, --- ~'tcueay.~
<br />WAS DECEASED ErER IN U.S. ARMED fORCFi7 ;INFORMANT-NAMF-FEU TIONSNIP-MAILING ADDRESS ISTl![T W [ F G. NO. Crtt On TD M. STATC L:a1
<br />3 (Yaf ar uni) il! ya., q w nor Dnd da+°. o vnwe! ~~BB
<br />,e 1Jn ~ ~,o.io.u CionbLRVrn-N]LAhnnrl-1414 N. LecEUtf-Gxend IePnnr7"_0~_
<br />
<br />( BURS IAt. CremaTlon, RamevalTDAT-E-IErn~ J4 +C~EMETI/RLY/.M CREMATOCRY-NA~MDEA LOCATION ~E(~~ CITY OR TOWE~N S~ j-~ST~ATE
<br />~Ii EMIALME~j~NaA7~~lIIIE dl~/~~E"NeoJ919 i fu~F pM~~ AME AND DDRESS fSTtf[T Of R.f D. NO. CI v/LE.OWLLTATEJ.RG41~~lGEE
<br />RI. / ~ ~ r T2. ~' - ~ L~O.QSE.L-
<br />' Ta M' 1 o inw adR• d un er Ma Kma. da N«. ewd Ma re .ba
<br />aewN. po
<br />~Z ~ Q Ma b N • hen« ndl« .„
<br />Ma ri.a, data end DI«. and duo a Ma < Qexan, in ti eplnien deeM ....A o+
<br />unNU .reM.
<br />
<br />Y ~ ~ _
<br />~ `
<br />17o.('eatwa end TidN~ 'L""~P
<br />\ °v.
<br />~np
<br />1de.fsipnoran end rxa/~
<br />L^
<br />~r ~ _...
<br />NOUf Of OEATK
<br />DAY ION D (Me., Dar, Yr.) ~ < ~ o. aY, r t A
<br />~
<br />tt
<br />i
<br />~ f~ ~ Th 7t~ pl M
<br />]Sb. ~' E5
<br />g~z
<br />1db.
<br />zk. M
<br />`
<br />~ _
<br />DATE OE DEATH !MO., Der, Yr.) ~~a PRONOUNCED OcwD -RONOUNCED DEAD (Kovr)
<br />~ /
<br /> E7d. { i . M
<br />NAM A DRE 5 tlF CERTIFlER (PKYSICUN. O ER' PMT ICIAN OR COUNTY ATTORNEYI (iYPe or Pdnq
<br />1i1e .~ LGndie hI.D 244$ €n,%dtw F_
<br />C"~n~d t n-fr/_ N 6BR01
<br />~REOISTRAR
<br />~C..C~~C~~~'iw~C.-L~C.~ ~
<br />OA E RE EI ED RY R 6 S (Mo., DoY• Yr.)
<br />~~ / ~
<br />Rbe.TfiReawgp' r
<br />~ Y86 .
<br />~7. IMMEDIATE GUSE ~~ ONLY ONE~USryE PE uNE f04 (o). Ib),
<br />~
<br />-~ MRT y AND (<!) - Ina..W 6 awp, ewd a.M
<br />l
<br />+
<br />!e, a 114.. k
<br />< RF.L.
<br />_~ U RA
<br />EOURNCE W:
<br />C
<br />' ~ Ina,.+t
<br />.r.e«
<br />~
<br />~
<br />~
<br />_
<br />/
<br />~ r /
<br />lni \
<br />~ ~_.L~. „-~
<br />OUE i0, OR AS A COHSE UENCE pF: In+.rnt b.Ea..e eeaar d.ed
<br />~ ~ (.'
<br />FART NiffCANT CONdTIONS -Cewdxiw a w iaeih nai wM rd.r.d PAar N R lEMMF, wAS MEN A AU
<br />' lNGMANCY Nr TN! FAST ] MON1K5} ISp«. an Ne
<br />11 F i ~ WAS T•.es ilFE MfpCAI
<br />) EXMi1N!! OR C !
<br />SpaedT TM « Nef
<br />-`/V L i7 1".1'x,-' f ~,I . ~jIIn'^C1~tG'".. W L`+.~ r.. ^ No 1R. 4' T9.
<br />Acao[m, sNrcace. iau[acwc, r .c q. -... .ten n..r
<br />Ot FEMRwO ,MVtlT16AflON fipw.E,l., -
<br />_ sl xM. SOb. 430t. M SOd.
<br />:' RYfillT AY 1Y0!! _ - - RACE Df 1!ylURY- M Iwe•. Fe.-, wn~r. ieeery, tOCAYIBN fTNtt W 1. t.0. lie tiTY i
<br />(L«JfF Yas w Nsl Nlka lwNiwg. a4. t3.aatY!
<br />'L so. f,Dr, i~
<br />,,.. •~.
<br />...
<br />. ; f
<br />_~ ,
<br />- >~ _
<br />~F1 ~Fi'I9y'i~E?i:Y CARRIES THE RAISEB SEAT, OF THE NEBRASKA
<br />~asT~„T~:~rRT~f~L`T f1g tiEALTIi, I'I' Gr.RTZeiES THE ARC3VE TF3 Ee
<br />°-- ~, ~`'t1~ ~~~~~ AN G1~IGI~IAL AECiIItD C11't F'TLR ~iT~`Ii T1[E STAB
<br />"' ~ ~,flB~P'Ak~jIB1~T: HEALTH, BUREAU QF VITAL STATISTICS, WHICH
<br />° !'~ r~f; '~HiL' G'A ~EPOSTTORY FO~R+j~ VITAL RECORBS n
<br />-`BIB ~TOR~VITAL STATISTICS AND ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA Issued August 27,1919
<br />
<br />
<br />
|