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as-Fr nos e 68gp r is a copy. Signa~ture~,sSTER OF DEEDS
COMPARE /~ adVare not original.
Date nitials
Northwest Quarter of Section Sixteen,•Township Six North, Range Twelve West of 6th PM,
Adams County, Nebraska
STATE OF NEBRASKA
WHEN THIS COPY CARRIES THE'RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND
HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON
FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES,. VITAL RECORDS
OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
DATE OF ISSUANCE ~ ~ .
STANLEY COOPER
MAR 2 6 200 ASSISTANT STATE REGISTRAR
DEPARTMENT OF HEALTH AND
LINCOLN, NEBRASKA HUMAN SERVICES
STATE UF' NE8RA5IKA' ;`'DEPARII'MEIV'!` OF'HEALTH ~~ {{~~
Bureau of-Vaal Statistics ~- ~'~ 11.Q11~'
v CER~`iFtCATE OE DEA'`i"H ~-s'
~- _ _ ~ ~ 1..'S LO ~ f/NTE ~Htl~ MIMttEt.:' ~' ... ~ ..
DECEASED-NAME fUil -_----- MIODIE lA1T ' SEA'- ' DATE'DEATH 1 MONTH, .DAY, TEAR) ~ '
,. Les13.e Fredric Gen 1• M a7.Q
RACE WNIn, NEGRO, AMlRISAN INDIAN, AGE.-+~IAfT VNOER 1 TtAR
ETC
I f-lCI-YJ !1 iND
Y yNDEt t DAr. DATE OF fIRTM I.+oN1T~, DAY, CCNJNTY Of TN
.
A
I YlARS I AWf. DAYf
+. ~.ite :
~a s` NOURf MIN. YEAR f
.
All 9 1899
~d
.
. :T. ~.
ams
T..
CITY, TOWN, OR LCKATION Cif DEATH INSIDE CRT twm
T ~ - ~ ~ - S.ECIr.T YES Ol
NO MOSF'ITAL OR OTHER WSTRUT -NAM 1!! NOT IN EITNlR, aIVE STREET wNp NUMRH:
.
T-. hastings ,T. Yes ~~ Zannin Fie~r:ial
STATE Of RIRTH I ff NOT IN V.S.A., NAME CITQEN OF WHAT COUNTRY MARRIED, NEVER MARRIED, SURVtVRdG SPOUSE t Ir wlrl,. arvE AIAIDlNy IIAAIE 1 T
Adams C.o. N CO°"~ I
R. ebr. t wo voRCED 1 f.EClrr,
U.S,A. arx~'e°~ to ~:T1Spa~u.
SCKIAI SECURITY N+JMRER USUAL OCCU-ATION I GIVE RIND or woRR DONE DwINa MOfT or KIND OF RUSRVESS OR INDUSTRY
~6-Z~- ~ ~
r:5 7 3 YVOtlfINO iIR, N!N Ir RETIRlD 1-
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RESIDENCE-STATE COUNTY CITY., TOWN, OR LOCATION INflot cm ElMlff STRS£T ANb
Nebraska
Iw.
„..Adams
„~. Holstein J fncur YES a No I
,,~. Yes
-+.None
FATHER-NAME rlpT MIOOI[ u:T MOTHER-MAIDEN NAME rNtsT MTOOIE IAfr
Is. Conrad Geritex''t ,EKatherine ir~i er
INFORMANT-NAME-.RELATIQNSHN MARgx~ ADOflf55 :StEESr et R.r,D. rro., .c,.^~r Olc Taw+:, sTa~, 2a,
„[, t~.rs Leslie ~'. Gentert ,,,. Holstein, Nebraska 6895fl
'ART I• bEATH WAS CAUSED 1Y: (ENTER O. !!Y ONE CAUSE PER IMfE FOR (a), (b J, ANO (c)~
rR. wwb1A1[ Uu ~E*wEpJ ONSET AND DEATH
~~, rDl respir~-tory sGrxteet 5 mantes
A A U
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IMMl DIwi! [wyiE IO) ,a, P~o~ ia8llfiiciai~C~1' alA~t2~
, DUE TO, OR AS A CONSEQYlNCf Or:
' SI ATING THE VNOER-
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'ulavnary eaphTaeala
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Y p
yeir8 .
.ART 11. OTHER SIGNIFICANT GCN+DITIONSI CONOITNN+S CONTRIRUTINQ TO DEATH RUT NOT RfIATED
TO CAUSE GWEN IN .
'
"~ MRT Ilt. If FEIAALE, WAS TNlRE A AIJTOISY IF YES WIRE IINOINaf CON-
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~1
t p]~~>•it2;' ATtCr'y MEGNANCY IN THE -A;t S AIONTHST 1 YES'OR NO/ SID[ab IN D[TEfrIN1110 CAVff
or OlATN
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ACCIDENT, SUICIF c, HOMICIDE, A 1 MONTH, DAr, YEAR 1 M UR
CMI UNDE TERMMVr:D 1 SrlCIrY I .
MOW INJURY OCCURRED 1 INTER NAtIlRE or INwRT fN /ART I OR .A[T 1e, In/A 1[ 1
20R. ~. 701. M TRf.
INJURY AT WORK
f SI[CIIY YEf De NO 1 -LACE CIF INJURY AT NOME, rAtM, sf[etr, !A[TORY,
OrfIC! E1Da., [Tt. 1 SrEClrr, .
LOCATICIN 1 fTtEtf OR R. r.D. NO., Cltt OR TOWN, STAn l
lOr, 2•f. ~,
CERTIFICATION-.. MONIN DAY YEAR MOI+M DAY Y[AR ANO UST SAW NIM/NH At1Y[ ON I DIO/DID NO7 YN'Y+ TI/! D[ATN OCCVRRED At 111E r1AGl
-HYSKIAN:
DN HI!
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MONM GAY YlAR ROpY ArTH Dlwin.
I AneNDeD TNt TO INOV[1 DAn, AND~IE~ Y~
tl[. DfCEASlD rROM $ ~ 2 ~ g in. ]- p I ~. ' 6 g :ic. 10 1I 6 9 :I,
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~AVflffl STATED.
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CERTIFICATION-MEDICAL EXAMINER CNt C ER: oN TNe lASls or TN! NoyR Or DIAM 7NI DtelatNT wA3 rRONOVNCtO DEAD
E RAMWATION Or IN! [OqY ANO/OR TN! INYESTgAT1pN
IN MY OIINN)r1
,
, MONT,1 DAY TEA! NOW
OtAM OCCURRtO ON 111E Owf! AND DU! TO THE CAUSl ISI STATED.
rn. M. m. U 6 9 8.3 S A M M.
CERTIFIER-NAME Inn of WINK ~SIGNA
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~UMAI, CRlMATION, REMOVAL C ETERY OR CREMATORY-NAME LOCATr un w TowN sTAn
I snnn .
:+.. Burial. 7,-St. ~'auJ.7 s Luther: 7~iolstein, I~braska 68950
OA1E I A.ONTN, DAY, ruR 1 fUNERAt HOME-NAAAE AND ADDRESS I suecT oR [.r.D. No., arY o[ TOwN, tTAn, .'-• /
'. 7++. p~'+i~1.ts- 969 n., -P Q Box G-I~ena_ s w rdebr. 689. 6
Eh1RAlAtER-SIGNATURE 8 U SE N REGISTRA GNATURE' C~a~~~j ~ ~ , A
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