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WHEN THIS COPY CARR�S THE RAISED SEAL OF THE iVEBRASKA HEALTH AND HUMAN SERV/CES <br />SYSTEIY� iT CERTIF/ES THE 9ELOW TO BE A TRUE COPY OF THE ORIQINAL RECO_!�3 O�It.FitE�AflTH <br />THE NEBRASKA HEALTH AND HUMAN SEItV/CES SYSTEM, VfTAL STAT/ST/C�S��I�, �f� <br />THE LEQAL DEPOSITORY FOR VITAL RECORDS. � � ^- i �,' <br />`� ��w�s`��_, � , <br />oa� oF�ss�,�►� 2�. 2 01413 __�� w"�r -_ <br />0 � �-__ _ � � <br />SEP 18 200Z _ a� r__��� o�' � <br />ASS/STi4�T STi�'fEREQ1S�'!� _`= <br />UNCOLN NEBRASKA HEALTH AND HUIW4NSERYICES SYS�I.-�= - <br />STATE OF NEBRASKA- DEPARTMENf OF HFALTEI AND IiUMAN SERVIC-F.S�FINI�1� SiJF�bRT <br />,��.STA�TTa - J��-��. 10 5 4 6 <br />CERTIFICATE OF DEATH -=_ - -- <br />1. DECEDENT - NAME FIRST MIDDLE LAST 2. SE% 3. DATE OF DEATH IManth Day. Yeer/ <br />Be Fer Berlie Female Saptember 14, 2002 <br />4. CITY AND STATE OF BIRTH lf/irof in USA. name wunby/ Sa AGE • Last Birthday UNDER 1 YEQR . UNDER t DAY ' 6. bATE OF &RTH � (MOnUa Dey. Yeaq <br />IYrs.l Sh. MOS. � DAVS Sc. HOUF� � MWS. <br />Franklin, Nebraska 71 ' ' November 8, 1930 <br />7. SOCIAL SECURTIY NUMBER - -� Ba PLACE OF DEATH <br />505-36-3260 HosP�T� ❑ i�o�em OTHER � Nws�ngHOme <br />8b. FACILRV-Name � I9rrotusGhrtian.9wesVeetarWnuinber) -.. � E�OW�eM � Reside^�e . <br />St. Francis Skilled Care Center � °OA � <br />Bt. CITY. TOWN OR LOCATION OF DEATH Btl. INSIDE CfTY UMITS 8e. CAUNTY OF DEATH <br />Grand Island Y� � � ❑ Hall <br />9e. - RESIOENCE -§TATE 8b. COUNTY 9c�. CfTY. TOWN OR LOCATION 9d. STREET ANO NUMBEfl //ntlud'mg Zip CodeJ 9e. INSIDE CITY LIMRS <br />N ebraska �_ Hall Grand Island 3215 W. 18th 688U3 Y� � N� ❑ <br />- - - -- -- <br />10. RACE -(e.g, White. Black Americen 6Wian. 11. ANCES7RY Ie.g..11a0an. Mexican. Derman. etcl 12 MARRIED ❑ WIDOWED 73. NAME OF SPOUSE Il7 wife. grve ma/den nemeJ <br />etc l IS ' � 1 <br />°�' White _�`�"� American N�� ONORCED �enr L. Berlie <br />❑_M ARRIED � ❑ Y <br />14a USUAL OCCUPA710N (Give k6d af wwtr dwre dming mast 74b. KIND OF BUSINESS IN WSTRY 15. EDUCATION (Speeify only Ngtreat grade wmpieted) <br />olworbn9file.evenHie6iedl Deme�'wSeccndery f0-121 � Co�e9e tt-aw5•I <br />Cler Reta Groc 1 Year <br />- -- - <br />-- - - - -- . <br />16. FATHER - NAME FIRST MIDOLE - LAST � 17. MOTHER - FIRST MIUOLE MAIDEN SURNAME <br />Charles Mucklo T Fern Reams <br />- - - _- - - - <br />18. WAS DECEASED EVER IN U.S. HRMED FORCE51 19a INFOPMANT - NAME � ' <br />�Yes. no. or unk) (tl Y� 9ive war etd Aates ot servkea) <br />No � --------- Henrq Berlie <br />-- - - _ _ _ - -- - <br />--- - --- -_ _ <br />19h. INFORMANT MA�LING AODRES3 (STREEI' OR R.F.D. NO.. CITV OR TOWN. STA7E. ZIPI <br />3215 W. 18th, Grand Island, Nebraska 68803 <br />��� BALMER • S�6NATURE 8 UCENSE NO. - -� - 21 a ME7HOD OF DISPp51T10N . 21b. DATE 21 C. CEMETERY OR CREMATpRV �� NAME <br />-dL lQ. �c,�.�-�Z�. � ���3 ��� ❑ Ra��� Se t. 17, 2002 Cedarview Cemeter <br />22a FUNERAL HOME - NAME � 21d. CEMETERY OR CREMATORY LOCATION Citt OR TOWN STATE <br />Livi ngston-Sondermann F.H. ��"°" �°"'�°" Doniphan, Nebraska <br />226. FUIVERAL HOME ADDRESS �SiREET OR RF.D. NO_ CIIY OR TOYVN. STATE, ZIP) <br />601 N. Webb Road, Grand Island, Nebraska 68803-4050 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la�. �b�. AND kll � truerva� be�vreen onse� aM tleam <br />rPARial .. , ��v"? 2 'J �. �� � I� J /� <br />_ -. __ _ _ _.. __ _ .. __ .__. _-_ . <br />� DUE TO, OR AS A CONSEOUENCE OF. � - �� �- - � � - - � Irrterval Datween on5e1 an0 tleath <br />I <br />I <br />(�1 I <br />- �-_ - - - - --- --- - � -..-. -.. . -.- . I Irterval between onset anL Aeath <br />- DUE TO.OR AS A CONSEQUENCE OF: � <br />I <br />1 <br />��� I <br />__ PART . -- � . <br />'I OTHER SIONIFICANT COIdOff10NS - Cmtlitlons contribuU� to the death bN'rot related PART III IF FEMALE. WAS THERE A 24. AUTOPSY 25. WAS CA5E REFERRED TO MEOICAL <br />PRE�NANCY M THE PAST 3 MONTHS7 L �E%AMINER OR CORONER'� <br />_--__._ ,---_: <br />� �Ages 10-54� Yes, � No � r Yes � No � Yes � No � <br />._ ___- __ _-_. - ..-_ _ <br />28a 26'b. DATE OF INJURY /Mo_ Dey. Yr.� 26c. HOUR OF INJURY � 28d. DESCRIBE HOW INJURY OCCURRED <br />� Accitlerrt � UntletertniireC M <br />� Suiade � PeMing 26e. INJURY AT WORK 26f. PLAC�( F� � Y%N� tarm. street factay 26g. LOCAIiON STREET OR R.F.D. N0. CITY OR TOWN STATE <br />oKCe • <br />� hbmicide Imeatigadon Yes � No � . <br />� 27a DATE OF DEATFI (Mo_ Day. Yr./ - 28a. DATE SIGNED /Mo.. Day. Y�1 28b. TIME OF DEATH <br />� � Se tember 14 2002 $ �W M <br />�� y 27b. DA7E SI NED /Mo_ Day. Yr.) 27c. TIME OF DEATH ' � k� 26c. PRONOUNCED DEAD lMC.. Day. Yr.) 28d. PRONOUNCED DEAD (Hanl � <br />��a� <br />� � ���6''C11.- � 2•22 A.Mo M �'�° � <br />; d � 27d To tlm besl M my knowiedge. uned ffitt��ee tlatgg ar�tl ate,e�d d� to qre «°- r Qi 2H8. On tlie beaia d e%amina6on aiW��or imestlgalion. in my opinion dealh occurred a2 <br />o ��¢ause�sl � �� A/� /! °� s► nre 6me. dare mw yace arid aue m ma eauae�sl �1a0ed. <br />« � �_�c <br />'_L �s�awra ane rme� ► �� �,i- � i_ �s��ew�e ar�e naei ► <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.8 HAS OROAN OR TISSUE DONATON BEEN CANS�QERED9 30.b WAS CONSENT GRANTED? � <br />'� � YES�NO � �UNKNOWN X� � YES � NO � � YES �O <br />r �.� <br />37. E AND nnnaccs ciF ERTI (PHYSICUW. CA NER' HYSICIAN OR COUNTY A ORN � -- ------- ��- .. <br />� �� .. ._.. <br />y �i ����o �• �'a�/�✓ �1rt �� ��'� ��3'i7�t '��l G�dG�' <br />32a i7EG1$TRAR 32b. DpTE FlLED BY REGISTRAR S E P y�� ry �OOZ <br />. �.�i�� . _ __ � <br />