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TYPE OR PRINT IN
<br />PERMANENT INK
<br />SEE INSTRUCTION
<br />MANUAL
<br />Ploce
<br />NSC
<br />Work
<br />uC
<br />Reject
<br />A
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALT*
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />DECEDENT - NAME FIRST MIDDLE LAST
<br />Walter William Riese
<br />5E%
<br />2. Male
<br />DATE OF DEATH (Mo., Day. Yr.)
<br />December 7, 1984
<br />RACE- (e.g., White, Black. American
<br />Md.on, OCT (Specify) ) (Sif
<br />4 . White
<br />ORIGIN/DESCENT (e.g.,Itolion,Meoican, (AGE - loaBirtday
<br />German, etc.) (Specify) - (Yrs.)
<br />5 Ameri , 8. 0
<br />UNDER 1 YEAR' UNDER 1 DAY
<br />DATE OF BIRTH( Mo., Day, Yr.)
<br />February 11, 1904
<br />MOS. . DAYS HOURS . MINS.
<br />6 I mo.
<br />CITY AND STATE 09.8I1TH (If not in U.S.A., .,
<br />name country)
<br />B. Holstein, Nebraska
<br />CITIZEN OF WHAT COUNTRY
<br />9. U.S.A.
<br />MARRIED. NEVER MARRIED,
<br />WI WED IV RC ED (Specify)
<br />IC t911.'
<br />NAME OF SPOUSE (If milt Viso maiden nom.)
<br />TI Helen Kramer
<br />-
<br />SOCIAL SECURITY NUMBER
<br />• 12. 508 -38 -15
<br />USUAL OCCUPATION (Give kind of work done daring most
<br />of ....king lift even if retired)
<br />130 Farrier
<br />KIND Of AUSINESS OR INDUSTRY
<br />1
<br />13bAgriculture
<br />COUNTY OF DEATH
<br />sea. Hall
<br />CITY, TOWN OR LOCATION Of DEATH
<br />1 grand Island, Nebraska
<br />l INSIDE CITY LIMITS
<br />(S pec ' Yes or No)
<br />rk• du'
<br />HOSPITAL OR OTHER INSTITUTION - Name (If nee in.ither,
<br />give ere I o number) 1
<br />(Id Franc Medical Center
<br />IF HOSP. OR INST. lodicate DOA,
<br />Oatparient(!Mi- Res ,. Inpatient (Sootily)
<br />14e Inpatient
<br />RESIDENCE - STATE
<br />15, Ne <
<br />COUNTY
<br />151. Hall
<br />CITY. TOWN OR LOCATION _
<br />15 Island
<br />STREET AND NUMBER' • .
<br />156606 N. Broadwell
<br />INSIDE CITY LIMITS
<br />(Specify Yes or No)
<br />see. Yes
<br />FATHER - NAME FIRST MIDDLE LAST
<br />16 .Henry NMI Riese
<br />MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />17_ Nellie NMI Winter
<br />WAS DECEASED
<br />;YS enk)
<br />,E
<br />EVER IN U.S. ARMED FORCES?
<br />I (II yet, give ap. and dates of service)
<br />N/A
<br />INFORMANT - NAME - RELATIONSHIP - MAILING ADDRESS' (STREET 02 R.F.D. NO.. CITY OR TOWN. TAT(, ZIP)
<br />h88D
<br />19.Helen Riese- wife -606. N.Broadwell,Grand Island. e.
<br />BURIAL, Cremation, Removal
<br />Burial
<br />20a.
<br />DATE
<br />Dec .10, 1981
<br />206,
<br />CEMETERY OR CREMATORY - NAME
<br />20 ,Cedar View Cemetery -
<br />LOCATION CITY OR TOWN STATE
<br />20d'. Doniphan, Nebraska
<br />EMBALM IGNATUR . ' LIC 'SE N .
<br />/ ��Y�
<br />FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.D. NO., cm OR TOWN. STATE, ZIP) 63801
<br />22 Liviniston- Sondermann, 505 a Koenig, Grand Island, Ne
<br />r
<br />To b. Comp lotod by
<br />Anondinp PHYSICIAN
<br />DATE D AT (Mo., Day, Yr.)
<br />23n.December 7, 1984
<br />To be CornploNd by I
<br />CORONER'S PHYSICIAN,
<br />or COUNTY ATTORNEY
<br />only.
<br />I DATE SIGNED (Mo. Day, Yr.)
<br />24a.
<br />HOUR OF DEATH
<br />24b. , ,A
<br />DATE SIGNED (Mo., Day, Yr.)
<br />t
<br />23b. ... , t 1 '$
<br />HOUR OF DEATH
<br />3: 0 0 P
<br />23c. M
<br />PRONOUNCED DEAD
<br />(Mo., Day, Yr.)
<br />24c.
<br />PRONOUNCED DEAD (Hour) -
<br />24d. M
<br />To the best d my knowledge, death occurred at the time, dote and place and due to the
<br />cause(s) stated E -- _ _
<br />•
<br />23d. (Signature and TWO • t---- . " . \ t17..----- \' ' L•► - .
<br />On the basis of examination and /ar investigation, in ayy opinion death occurred at
<br />Me rime, dote and place and due to Me couse(5) stated-
<br />24e. (Signature and 79.) .
<br />NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ• or Print)
<br />25. W.J.Landis, M.D. 2444 Faidley, Grand Tsland "Ne_fRR01
<br />REGISTRAR
<br />26a. (Si9na1re) 0 - F
<br />DA RECEIVED BY REGISTRAR (Mo., Doy, Yr.)
<br />26b4
<br />27. 3MMEDIATFCAUSE (ENTER ONLY ONE CAUSE PR t LINE FOR (a); (b), AND (c)) t. (i t Interval before and death
<br />PART ,l c - 1 w
<br />DUE TO, OR AS A COtISEQUENCE OF: ! _
<br />e. 3 h`\ \ Intense between onset an th
<br />•
<br />DUE TO, OR AS A CONSEQUENCi OF: . Interval between end death
<br />•
<br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to death but not related
<br />- t _ . r-
<br />U
<br />... - -/ - c- ...0--%. •'' C. ti') r -- --� 1\ .c. . . t ti . 'L
<br />PART 111 IF FEMALE, WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />Yes [11 No ❑ ..
<br />AUTOPSY
<br />(Specily or No)
<br />28. i.....
<br />WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR C E �
<br />( ecify Yes / or No) V
<br />ACCIDENT, SUICIDE, UNDET -,
<br />OR PENDING INVESTIGATION. (Specify)
<br />30o.
<br />DATE Of INJURY (Mo., Day, in) '
<br />30b.
<br />HOUR OF INJURY
<br />- -
<br />30c. M
<br />DESCRIBE HOW INJURY OCCURRED •
<br />- -
<br />30d.
<br />INJURY AT WORK
<br />(Specify Yes or NO
<br />.30e.
<br />PLACE OF
<br />office building,
<br />30f.
<br />NJURY- At home. ferns, street, faders, -
<br />etc. (Specify)
<br />LOCATION STREET OR R.F.D. No. CITY OR TOWN STATE
<br />30g.
<br />TYPE OR PRINT IN
<br />PERMANENT INK
<br />SEE INSTRUCTION
<br />MANUAL
<br />Ploce
<br />NSC
<br />Work
<br />uC
<br />Reject
<br />A
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALT*
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />
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