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' STATE OF NEBRASKA � �"����� �
<br />I WHEN TH/S COPY CARRIES THE RA/SED SEAL OF THE NEBRASKA HEALTFI A
<br />i SYSTEM, ►T CERTIF/ES THE BELOW TO BE A TRUE COPY OF THE OR/CaINAL R�FLD �11 -�7_C7�9[ITH
<br />i THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTl�S ��'FI@l�t-�f€1.S
<br />; THE LEGAL DEPOSITORY FOR VITAL RECORDS. - = -
<br />I _ ,J� � I
<br />� DATE OF /SSUANCE k� �"="u-�-'� `- -
<br />� ' , . TANt�i!�"�1-�O�ER
<br />_- --- UN 2 2 ZOI� `�ssi��aru� srarE ���sr��r= �.
<br />LINCOLN, NEBRASKA � • l HE4LTI�N6fJ __(1�4AL�EB�DICE�
<br />� t. _ -- _ �
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SI7PP'F3 Y
<br />CERTIFICATE OF DEATH ��� �� � � � �
<br />t. DECEDENTS•NAME (Firet, Middle, Lest, Suf(Ix) 2. SEX 3. DATE,OF DEATH (Mo., Oay,Yr.)
<br />J� Edward Nb1e .T..me 12 �06
<br />4. CITY AND BTATE OR TERPITORY, OR FOREI�N COUNTRY OF BIRTH 6e. AQE-Lael Blrthdey 6b. UNOER 1 YEAR 60. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Dey, Yr.)
<br />(Yre.) M09. DAYS HOURS MIN3.
<br />Aberd�n, ��ta 85 r ZD 1921.
<br />7.30CIA &E NUMBER ' Ba. PLACE OF DEATH
<br />4�"�.�r7193 H03PITAL: O 1npallent oTM�x SI NureingHome/LTC ❑HoapiceFeolllty
<br />Bb. FACILITY-NAME (If not institutlon, give eireet end number) ❑ ERIOUtpetlem ❑ DecedenYeHome
<br />vetec�s Affai�s r.�aical. c�ter
<br />Z7A1 N. Broa�71� (�and Islarld, NE 6�03 ❑ oo� ❑ rnner(s�a
<br />8c. CITY OR TOWN OF DEA1N (Include Zlp Code) 8d. COUNTY OF DEATH
<br />C�. I31c''�']�. j�]
<br />9a RESIDENCE-STATE 8b. COUMI' Bo. CfTY ORTOWN
<br />� �. �. �.
<br />Bd.BTREETAND NUMBER Be. APT. NO 8i. ZIP COOE 8g. INSIDE CI7'Y LIMITS
<br />1.6� �tCt�1 �L�. � �I YE9 ❑ NO
<br />t0a. MARITAL STATU3 ATTIME OF DEATH � Mercled ❑ Never Married tOb. NAME OF SPOUBE (FIraL Middls, Last, Suitix) If wHe, give melden neme.
<br />❑ Marrled, buf aeparaled ❑ Widowed ❑ Dlvorced ❑ Unimown Zita Marie Osmers
<br />11. FATHER'S•NAME (Firat, Middle, Laet, 9uflix) 12. MOTHER'8-NAME (First, M�ddle, Melden Sumame)
<br />Paul E. Gayer Mamie M. Yiltalo
<br />13. EVER IN U.S. ARMED FORCES? Qive detea of service it yea. 14a INFORMANT NAME 14b. RELATIONSHIP TO DECEDENT
<br />(Yea,no,orunk.) .AYId�T 9�Z��FZ Zita Marie Gayer Wife
<br />15. METHOD OF DISPOSITION i8a EMBALMER3�QNATURE � �� 18b. LICEN3E N0. 18c. DATE (Mo., Dey, Yr. )
<br />�Burlal � ❑DoneUon ��,�Z.S� June 19 � ,2�06
<br />❑ Cremallan ❑ Entombmeni 1'Bd. CEMETERY, CREMATORY OR 0 ER LOCATION CITY / TOWN 3TATE
<br />❑Ramwal ❑rnna�(sPaony� Grand Island Cemetery, Grand Island, Nebraska
<br />17aFUNERALHOMENAMEANDMAILINOADDRE39 (3Ueet,ClryorTown,Slate) 17b.ZIpCode
<br />Apfel Funeral Home, 1123 West Second, Grand Island, NE 68801
<br />t& PART I. Enter the ohein af events-dlaeaaea, in�urles, or compliceUona-that dlrectly caused the dealh. DO NOT enter terminei eventa euch es raMao artesl, � N'PROXIMATE INTERVAL
<br />reaplralory erresi, or venMcutarflbrlllaUon wlthout ehowing ihe etlology. DO NOT ABBREVIA7E. Enter only one cauae on a Iine. Add edd(llonel Ilnea B neceaaery. �
<br />� IMMEDUITE CAU8E � onsei M death °
<br />I
<br />IMIdEDIATECAU3E(Fltml (8)
<br />�LLC � � � - �St I
<br />��°r�°�°����U�9 DUETO,ORA9ACONSE�UENCEOF: I onsaitodeath
<br />��+1 I
<br />8equeMla��gnatconmuo��R ro) 1�.CaT"� I
<br />enY�leadl�tothecausellaffid ' I
<br />DUE T0, OR AS A CONSEQUENCE OF: I onaet to death
<br />on Ihre e.
<br />EnlBf6�0UNDERLYWOCAUSE , I
<br />(dlseaeeminJurythat6dtleted (�) PYt76fis�.tE � Q�l �+ �
<br />�������d�) DUETO,ORASACONSE�UENCEOF: � onsetrodeath
<br />� , ���� � �
<br />' (�. I
<br />18. PART II.OTHER 31QNIFICA ONDRIONS-Cond�lone con buting to the death but not reeulU� in the underlying cauae gtven in PART I. 18. WA3 MEDICAL EXAMINER
<br />�' �� � ���� ORCORONERCOMACTED7
<br />❑ YES � NO
<br />20.IFFEMALE: 21a.MANNEROFDEATH 21b.�FTRAN9PORTATIONINJURY 21c.WA8ANAUTOP3YPERFORMED?
<br />❑ Not pregnent wilhin peat year �Netural ❑ Homicide ❑ DrivedOperaWr
<br />� ❑ YES �NO
<br />❑ Pregnent el llme of death 0 Accldeni❑ Pending IrneaUgetlon .
<br />❑ Nol pregnanL bul pregnent wflhln 42 deys o1 death � P ���� 21d WERE AUTOP9Y FMDW�S AVlULABLE TO
<br />❑ su�ae ❑ CoutA not be determineu p�y,er �specity) •
<br />❑ Not pregnent, but prep�nt 43 deya ro t year before dealh COMPLETECAUSEOFQEATH4
<br />❑ Unknownitpregnentwfthinthepestyear ❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, atreet, tactory, offlce bullding, conetruotion eite, atc. (Speolfy)
<br />m "
<br />22d.INJURYATWORK? 22e.DESCRIBEHOWINJURYOCCURRED
<br />❑ YE8 ❑ NO
<br />22t.LOCATIONOFINJURY-BTREET&NUMBER,API:NO. GTYlfOWN S�UE DPCODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) � 24a. DATE S�ONEU (Mo., Dey, Yc) 24b.TIME OF DEATH
<br />�'� J�e ]Z 7�J06 .�� "'
<br />�,
<br />� r 23b.DATE310NED (Mo.,Day,Yr.) 23c.TIMEOFDEATH ��� T 24a.PRONOUNCEDDEAD (Mo.,Dey,Yr.) 24d.TIMEPRONOUNCEDDEAD
<br />��o . m �6QO m
<br />W
<br />23d. To the eat my knowledg deaih occuned at ihe time, dete and piece $�� 24e. On the baels of auaminetlon end/or hrvestigetlon, in my opinlon death oxurred et
<br />�� e d e e cauae(s) ed. (Signature and Title )♦ ' .� �$ the tlme, dete end place end due to the oause(s) etated. (9lgnature end Tllle )♦
<br />� fi� lr-�-' �� ~ 8 s
<br />26.DID70BACCOUBECQ BUTETOTHEDEATH7 28a.HA30RQANORTI3SUEDONATIONBEENCONSIDERED? 28b.WA3CONSENT6RANTED9
<br />❑ YE3 ❑ NO ❑ PROBABLY � UNKNOWN ❑ YES � NO Not Appllceble 1128a Is NO ❑ YE8 ❑ NO '
<br />27.NAME,TITLEANDADDRESSOFCERTIFlER (PHYSICIAN,CORONER'SPHYSICIANORCOUNTYATfORNE1� (TypeorPrim)
<br />I�. Vim�la P� UA 1'�di.cal C�ter 22(Tl. N. �io�l]. Ave.
<br />2Ba RE�I3TRAR'S SIONATUflE 28b. DATE FILED BY REOI9TRAR (Mo., Day, Yr.)
<br />,(�. �ft1N 21 F006
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