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<br /> ; , George "�;�:� Carstens �� male �, .1une 13, 1978
<br /> I �RA�E-- ;NF�.t rlPlnri. �� ' � T r ;�/r' -.I;�r...M �:.vn �'YGSEI ;�.� �.AaY i. ,�UN.^,F4 ;�E4C _ )'3CfG 1 MAY �UAIE G�F.�G'H '.�:
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<br /> nc,me �.�n� wrb��:t�'pL DIVG+��FD;Sprc�lr��� , . � • �. � .
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<br /> e Roc�:ville, !�E !s U.S.?.. �n i,, Ciara M. O',,r:milirr
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<br /> SOCIAI SECUAiTYNUMBER �I�SUai O.i_�Ff iC!�/G; r L��doi..o.L d,��r i � ��.: ,�r:i �:':C�.'RUSIr�E!SO�IhDUSTRY �CC%��i�',��F C:iA1H
<br /> �ol..��k.�y Llr . �e�ll,eh�ed! i
<br /> 1z 506_14-0384 _ i�,o F�al��ner Fai�ming j,,, }iall
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<br /> UTY,TOWN OR IOCATION Of DEATH 'I Ir�51DE CfTY tIMITS�!+i>SF'i1At OK JTf+E '.:N�iiTUr��N� u��.e il���ol n c�lhe�. ��` �u:� OA'.�+5• d�o•. :��:�♦
<br /> '$n Jfv Ye, �No/ �y;•e sf C ,�, 6e/j �0,.•�,��,.�rf.�.e� R��
<br /> Grand Island � es� 1h����os ital '
<br /> Ub 14c� � ��ad � �'�14� iii���lt1El�it
<br /> --- --- - __ __ __ __. . ___ __. . _ _
<br /> RESiDENCE-S1hTE �COUniTY �CITY.TO'+v'.Oe'�.UCATiCN 'SIFEET atiJ�:UNBER n; ;�� � � .
<br /> ,So 1�ebraska !,5e Hall i,s� Grand lsland ,Sd 811 �;est John ,�,t , -s��
<br /> FATHER-�NAME� FiR$T MiDDLE- - :.�ST ,N,GTrER� -MA�vFti N�.ME - FIRST M�`.)DlE .FST
<br /> 16 (dec.) _Jurgen _ _ _ Carstens 1„_(dec.) Dorthea '7o�•ck
<br /> WAS DECEASED EVER IN U S ARMED FORCES? !NFORMANi ��NAMF-RFtATIOh'SH1P MAIIING AD�t�S� ��tiCS t'REI�IR�D NO.�[irr Go T��wN, :'•'�4:io��
<br /> ;r.�.�o. � :.�o� U�r.. ,r..a,u�d d o >r�...7
<br /> ,�'es�N'lVi �8 2� 18f 6 10-19 ,9hSrs. Clara Carstens,wife,Grand Islarid, NE 6Sf�01
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<br /> � BURIAL,CR.MA710N R'_MOVAI �DATE !CCME7ER:' Ok CF ,4'JRV r�4ME '.:.�..:�v�• tl�i�• ivwh � n�c
<br /> ___ -
<br /> ____ _ Burial zo�-16-78 Westlawn l�iemorial Park_� GrFS.71d I51�r!�, T;e.
<br /> zoa. zo�. aod.
<br /> EMBAIMER-SIGNATURE 6 LICENSE NO. FUNERAL MOME-NAME AND ADORE55 �SiecEi O�a.r c r,,.,c:':cc iv�+N,Si.�i[,t/Y)
<br /> z,. 1820 z2 Livingston-Sondermann,505 !�.Koenig�Graxid Is1n�.nd�2de,6S8_z
<br /> To�he it ol my knowledy�,dw�h occ�..ed a�the Hme,dote and ploce ond dve ro the On rFe bo.i.of�.um���o��oa nd;o.��•e�ngm�on,in m opioloo deo�h«c��rd a�
<br /> � <o��H�l.�e�ed. ,_-.�, ♦ ' ��Z> ehe���.e,do+e ood ploee o�d d�e ro rhe�ooul+).�aiad
<br /> �< ,,�,. ^ /� r//, // �s�Z
<br /> ev 23a.f5�gnorure and Tillel• /V ~- 'L'���+=' � ' �' (�:�'L� ��V° (�da.(S�gnal�re ond T��lei� �
<br /> ___ '- _— ' __—.�_._•�..---..-�.,�n O
<br /> F___-______----
<br /> :�> DATE SIGNED Mo.,Do �
<br /> ' ( y Yr./ OUR OF DEATH �1p i T�GATE SIGNED(Mo Doy,Yr.) HOUR OF DEATM
<br /> �Z' -�
<br /> �� Jul 7 1978 3 05 °",
<br /> �.� �436. Y s 23c. P h� �`�W Z�I 2ab. ?�c. ----- /.�
<br /> -------- -- �� -- - --- -. ...- --- -
<br /> � IPRONOUNCEDDEAD(M Doy,Yr) 'PRONOUNCEDDEAD/HourJ � �r�C GRONOUNCEDDEAD PRONOUNCEDDEADrHour) �
<br /> i � �°p o I(MO Doy.Yr.1
<br /> - ---z3d _June 13, 1978_ --- ?,� 3.05p �
<br /> _. .__._. —M . _. _I74d __ ____-___—_.__. ?Ie- .--______._.. �`�`
<br /> NAME AND ADDRESS OF CERTIFIER(PHYSIUAN, CUAONER�S FHYSICIAN OR COUNTY AiIORNEY)(iype o.Pr�nl)
<br /> �R�nRAqueta A. Bellosillo M.D. VA Hos ital 2201 N. Broadwell Grand Island NE 6880?
<br /> ,, , p , , ,
<br /> - - -- --- - -_ _ . --- -- --
<br /> • / � � DAIE RE IVEL/�BY REGISTRAR(Mo.,Dor Y )�
<br /> .I 27a.:(IMMEGIA• �._� ' l L.b-L�f�"' " / . � �G`L"�`/ ���
<br /> ' y o��,., �/ 266.-�"
<br /> -- - -- - ---� - - - -- -- ----�----- ----- - - -._._. . . _
<br /> TE,CAUSE � �NL�'ONE C?USE FFR LWE iUR(a).(b!, AND(c)) �r I��e..ol be�..er�on.e o�d n.oro
<br /> °ART
<br /> __;e, Arteriosclerotic heart disease ; unknown
<br /> ---- -------------
<br /> DUE TO,OR AS A CONSEpUENCE OF: � - -
<br /> - i„�.,.ai c.._.��a,..�o�d a.o��,
<br /> �
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<br /> DUE TO,OR AS A CONSEOUENCE OF: ; I��...oi b.ti.e�o�.e,o�d d.om
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<br /> � pqRT O:HER S�GU1fICA1:l CG�DITIONS-Cond�fion�ionlrib�i�ng to daoth b��not.elaied YAR7 ill.IF fEMALE.WAS iMERE A �AUTOYST —AS CASE REfERREG 1C MEDICAI
<br /> _ � �� VREGNANCY IN 7ME PAST 7 MONTNS? (Sp•ailr Ye.o.No) Ez.ueINER OR CORONER
<br /> ' � Ne hrosclerosis ��, o No a `5p":`'�"°`"°,
<br /> z8 no 29. no
<br /> �� ACGIDEN7,SUICIDE,MOMICIDE,UNDET., I DATE OF INIURY(Mo.,Dor,Yr.l HOUR OF I W URY DESCRIBE MOw 1NIUR�OCCURRED
<br /> g._._. ._ ., ON PENDING INVESi1GAilON.(Spe�ilr)
<br /> 30a. 306. 30c. M 90d.
<br /> ---- ---'.------------- --------
<br /> --------._..----.._-----.._._..
<br /> IN/URY AT WORK �PIACE OF INIURY A�home form sl�ee� larlory �LOCATION STREEI OR R.F.D No CITY OR TOWN STATE
<br /> Spe�ilr Ye�o.No) ll��e b��lding N< (Specily) �
<br /> '30e _ 301. - - -- �30g- � ------------------ -
<br /> , WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br /> � STATE DEPARTMENT OF HEALTH , IT CERTIFIES THE ABOVE TO BE
<br /> A TRUE COPY OF AN ORIGZNAL RECORD ON FILE WITH THE STATE
<br /> DEPARTMENT OF HEALTH, BL'REAU OF VITAL STATISTICS , WHICH
<br /> IS THE LEGAL DEPOSITOFY FOR VITAL RECORDS .
<br /> �'�r�� e?-1�-�
<br /> DIRECTOR OF VITAL STATISTICS AND ASSISTANT STATE REGISTR.AR
<br /> LINCOLN, NEBRASKA Issued July 14, 1978
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