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STATE OF NEBRASKA _--�":,:` �,-� �
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT �H�E.TH �411ft� HUMpi1fSERVIC S, IT.CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEB�,4S1C�1 DEPARfiJk1E#V,T 0�' H��LTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR Ill�Al�_ RECO ` S�.. ,:`' •,
<br />�., � ; F
<br />��������� -
<br />DATE OF ISSUANCE - p ' �� , : ; � .
<br />01/26/2012 2 012 0 41 ��-'' �T,����5. �.� � , �a .,
<br />. kSSI�TA,NT �57",�T� /3EG�STRAf� "' �;`
<br />DE,P,AftTMEN�f O�'fI�ALTH'ANA '
<br />LINCOLN, NEBRASKA H,UMA�f 3ERVICES ',":� �, ' �`'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVfQE$ +,." �� ; r ,� ;^
<br />-------- -- - -- --.. .. , . ,'; o ,.� �»'12 00142
<br />ctrc i �r��p►i t c�r urr�i n , .s , •
<br />1. DECEDENTS-NAME (First, Middle, Last, Sufflx) 2. SEX �`„ 3,,� _ 3 pi'E OF DEATH (Mo., Day, YrJ
<br />Doroth G Hoffmann Female ,•� ;. ` January 6, 2012
<br />4. CI7'Y AND STATE OR TERRITORY, OR FORFJGN COUNTRY OF BIRTH 5a. AGE - Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY ,; , B: pATE OF BIRTH (Mo., Day, Yr.)
<br />(�'B�) MOS. DAYS HOURS NONS'�, > � � � �
<br />Hastings, Nebraska 93 October 29;-1918
<br />T. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />505-14-1013 �IOSn PRA6 � InpaUent OTHE � Nursl� Home1LTC � Hoaplce FacIIKy
<br />8b. FACILITY•NAME (H not IrreUtutlon, gNe street and number) ��/p��M � pecedeM's Home
<br />C
<br />� Good Sam. Society-Hasdngs �Ilage, Perkins Pav. ❑ oon ❑ ocner (sPec�ry)
<br />� 8c. CITY OR TOWN OF DEATH (InClude Zip Code) Sd. COUNTY OF DEATH
<br />o Hastlngs 68902 Adams
<br />� 8a. RESIDENCESTATE eb. COUNTY 9e. CITY OR TOWN
<br />w Nebraska Adams HasUngs
<br />LL 8d. STREET AND NUMBER e. APT. NO. 9(. ZIP CODE 9g. INSIDE CITY LINOTS
<br />�, 926 East E Street 68901 � ves ❑ No
<br />'° 70a. MARITAL STATUS AT TIME OF DEATH Q,Marrled � Never Married 10b. NAME OF SPOUSE (Fl�st, Middle, Last, Suffix) If wHe, gNe malden mame
<br />9
<br />� ❑ n�Riaa but separated � vsnaowea ❑ owo��a ❑ unk�ow� Theodore Hoffmann
<br />m
<br />� 11. FA7HER'S-NAME (flrst, Mlddie, Last, SuHbc) 12. MOTHER'3-NAME (Firat, Mlddle, Maiden Sumame)
<br />� George Ruhter Sophie Meyer
<br />E 13. EVER IN U.3. ARMED FORCES? Give dates of aervice H Yes. 14a. INFORM/WT-NAME 74b. RELATIONSHIP TO DECEDENT
<br />$ (ree, No, or unic.) No Madeline Kmiec Daughter
<br />� 1S. METHOD OF DISPOSITION 16a. EMBALMERSI(iNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F �„ � Burtat ❑ Donadan
<br />Henry Opbr�k 1147 January 10, 2012
<br />❑ CremaUon � Errtombment �� CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (SpecHy)
<br />Concordia Cemetery Juniata Nebraska
<br />17a. PUNERAL HOME NAME AND NWUNCi ADDRESS (Street, City or Town, State) 17b. Zip Code
<br />Jackson-Wilson Funeral Home, 209 N. Smith Ave, PO Box G, Kenesaw, Nebraska 68956
<br />AUSE OF DEATH See nstructlons and exam les
<br />1& PART L Frrter the shaln at evema� 4lseasea, inJuNee, or comppcadonrthat Airectly causetl the tleath. DO NOT eirter terminal eveirte such es cardlac arrest, ; ApPROXIMATE INTERVAL
<br />r�plretory artest, ar veMriwtar flbrlilation wRhout shawinp tlre edobgy. DO NOT ABBREVWTE Fster onty o�re eause on a Iina Add adtlitlonalli�res If �ry.
<br />IMMEDIATE CAUSE: ; oreet to death
<br />I�MEDIATE CAUSE (Flnel a1 Lymphoma ; 2 Weeks
<br />dlaeaee or eondtdon resuitlnp
<br />� d �'� DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />seque�any uac conamo�, it b)
<br />anY. Ieaaine to the muse Uated
<br />on tl�re a. DUE TO, OR AS A CONSEQUENCE OF: 0 oneet to death
<br />Ente�the UNDERLYINO CAUSE C �
<br />(dieeaw or Injury that Initlated �
<br />the eveMe resuttinp In death) DUE TO, OR AS A CONSEQUENCE OF: : orreet to death
<br />� d)
<br />18. PART II.OTHER SI�NIFICANT CONDITIONS�Condkio� coM►ibutinp W the death but not resulUng in the urMerlying cauae gNen In PART 1. 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />a , ❑ YES � NO
<br />W 20. IF FEMALE: . 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJU 21c. WAS AN AUTOPSY PERFORMED7
<br />{L
<br />� � Not prepnaMwithln past year ��w� � Homlcide � Drhe70pereMr � y � � No
<br />v � P�e�M � n� ar d�ri, p a�am�e � PanNnB ImeatlBetlon ❑ a��e
<br />� � Not prepna�u, but preg�nt �rtthln 42 tlaye ot tleath gWCide Could not be demrmt�retl � P��e� Z�d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />�,, � Not prepnant, but preB�►49 AaYe ro � Y� �� death � � � � pther 18pectry) TO COMPLETE CAUSE OF DEATHT
<br />� � Unknown li prepnarrt wMhin the peat year ❑ YES ❑ NO
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY ZZc. PLACE OF INJURY•At home, farm, street Tactory, oftice bu0di�, cor�struction site, etc. (Specffyr)
<br />$
<br />.� 22d. INJURYAT WORKT 22e. DESCWBE HOW INJURYOCCURRED
<br />f
<br />❑ YES ❑ NO
<br />22L LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITYlfOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIONED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />S January 6, 2012 ,� � �
<br />� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH �� 24e. PRONOUNCED DEAD (Mo„ Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />$ o Janua 19, 2012 01:12 PM � d<�
<br />� sa. ro sne eeas m my www�eaea. aemn oca,rrea ae um e� date �d plaw °
<br />T4e. On Ne bads of e�Mretlon mM/or Imeatlgatlon, ln my oplNOn death occurred e!
<br />�� ana due so are causa�e► s�ea.lsie�+re ami nae) �� the dme, tlate end place anG Gue to the muae�e) smted. (SiOnature and TRIe)
<br />'- Peul Wfbbels, MD ~ o
<br />2S. DID TOBACCO USE CONTWBUTE TO THE DEATHI 26a. HAS OROAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN � YES ❑ NO Not Applicable H 28a Is NO ❑ YES � NO
<br />F IF ER {P IC , Y I R R RN (Type or riM)
<br />Paul Wibbels, MD, 2115 N Kansas Avenue, Hastings, Nebraska, 68901
<br />28a. REGISTRAR'S SIGNATURE �_ 28b. DATE FlIED BY REGISTRAR (Mo., Day, Yr.)
<br />January 20, 2012
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