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1 DECEDENT • NAME FIRST MIDDLE LAST <br />• Leona Ann Gebers <br />2 SEX 13 DATE OF DEATH (.401. ' Day 248 <br />Female 1 September 12, 2004 <br />4 CITY AND STATE OF BIRTH 'ding/HUSK. nano cO ata'Yl <br />Rural Grand Island, Nebraska <br />S.. AGE • Lap Monday <br />10111 <br />71 <br />UNDER I YEAR <br />UNDER 1 DAY <br />8. DATE OF BIRTH /Mor&. Day YBa,1 <br />December 7, 1932 <br />SD MOS I DAYS <br />; <br />Sc. HOURS MINS <br />7 SOCIAL SECVRTIY NUMBER <br />505 -38 -5825 <br />Ba PLACE OF DEATH <br />HOSPITAL 1 <br />❑ <br />1 <br />tdoaem OTHER gl <br />ER 0Jplaota a <br />❑ <br />Ha Home <br />Hamm <br />Randence <br />Omer <br />Stl FACILITY• Name AInol.nv n Mom omaod nW.eM4 <br />L Beverly Healthcare Park Place <br />DOA (Speedy <br />& CITY TOWN OR LOCATION OF DEATH <br />Grand Island <br />8d INSIDE CITY OMITS <br />Ys IF No ❑ <br />8e COUNTY OF DEATH <br />'Hall <br />9a RESIDENCE • STATE <br />Nebraska <br />911 COUNTY <br />Hall <br />9c. CITY. TOWN OR LOCATION <br />Grand Island • <br />9d STREET AND NUMBER /nCAttalgZV Code' 188 INSIDE CRY UNITS <br />2418 N. Ho 68803 1 Ys n No ❑ <br />t0 RACE - 0. Whig. Amman Indian. <br />p <br />MI Moody' White <br />11. ANCESTRY M g. 1010o. Mena?. Osman 12. Icy'( MARRIED II WIDOWED I13 NAME OF SPOUSE la1468. 080LVd1 nasty <br />' German /American D "D ?DIVORCED Edmund D. Gebers _ <br />14a USUAL OCCUPATION /GM kind caand( ,8oN(Migmost <br />lowing Ab- ova Anroadl <br />S /Bookk eeper <br />145 HIND OF BUSINESS INDUSTRY <br />Gas Station <br />15 EDUCATION Moody only Naha* 9 <br />EMmarnarya SattlndalY 10421 College It -N 0. S-t <br />8th Grade <br />IB FAT •NAM ecretary <br />FIRST MIDDLE LAST <br />Armin F. Danke <br />17 MOTHER RRST MIDDLE MAIDEN SURNAME <br />Lilian • Schobring <br />18 WAS DECEASED <br />(Yes. no. W 01114 <br />I No <br />EVER IN V.S. ARMED FORCES? <br />(a yOS. pee oar ma dales d aorvlop4 <br />1914 INFORMANT <br />Edmund D. Gebers <br />155 INFORMANT MAILING ADDRESS 'STREET OR 0 F D NO. CRY OR TOWN. STA DPI <br />2418 N. Huston, Grand Island, Nebraska 68803 <br />20 F SWNAT XLC NO. <br />AZ( � /l /� <br />2114 sIETHODOF 04POSITtON <br />[ 81n� 0. <br />210 DATE <br />Sept. 16, 2004 <br />211 CEMETERY OR CREMATORY NAME <br />Westlawn Memorial Park <br />22a F HOME • <br />Livingston - Sondermann F.H. <br />❑c'.".im ❑D.... <br />210 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Grand Island, Nebraska <br />225 FUNERAL HOME ADDRESS (STREET OR RF.D. N0. CITY OR TOWN. STATE DPI <br />601 N. Webb Road, Grand Island, Nebraska 68803 <br />Meng bpanan and and dean <br />X PMT IMMEDIATE CAUSE TENTER ONLY ONE CAUSE PER LINE FOR MI. 154. AND kid 1 ✓ <br />1141 BREAST CA / COLON CA t 3 MONTHS <br />is DUE TO.' OR AS A CONSEQUENCE OF Mend mowed 0.104 and deem <br />IW t <br />I Mama' between onset and loam <br />DUE TO. ORAS A CONSEQUENCE aF• i <br />IU <br />OTHER SIGpFICANT CONDITIONS • Cant/sons c PTbOWq to llo deaat MA rot /Nebo <br />PART <br />& <br />IDDM , CA THYROID ,ATRIAL FIB <br />PART Ie IF FEMALE WAS THERE A <br />PREGNANCY N THE PAST 3 MONTHS? <br />Moos 10•54I n NO f ir,.. Vas <br />214 AUTOPSY <br />.a ❑ No <br />25. WAS CASE REFERRED TO MEDICAL <br />4 / EXAMINER OR CORONER? <br />Yes n ND n <br />26. <br />0 8 1 11 01 0 8 . 4 <br />• S.oc de ❑ Penang <br />• HOntclde 111 <br />286 DATE OF INJURY 1AID. Day- Cal <br />26e HOUR OF INJURY <br />M <br />261 DESCRNE IOW IN.JRY OCCURRED <br />28. INJURY AT WORK <br />US ❑ No ❑ <br />254. Q MUMRY: I.0 t 7. lvm. seep McVey <br />260 LOCATION STREET 00 RFD. NO CRY OR TOWN STATE <br />g <br />a <br />27a DATE OF DEATH /Xb_ Day. 1,4 <br />X September 12, 2004 • <br />S <br />24 DATE SIGNED IAb Day 111 <br />286 TIME OF DEATH <br />M <br />2711. DATE SIGNED /Mo. Day Y,1 <br />r September 13 , 2004 <br />27c TIME OF DEATH <br />05:30 P.M. M <br />t <br />_ ` <br />2& PRONOUNCED DEAD 18b Day 1,1 <br />291 PRONOUNCED DEAD (MI <br />M <br />VS. To en bepdttry knowledge. daaMOCCUrtod al'MaBtlta, ddale <br />le camels( Natal <br />(SglO S TOM P. <br />and dttegb <br />P 14. On OaendaaallrtaMYt alp dt atY e9epMpine1,.91w'at mad, <br />28 <br />0 9n erne. oar aM 'Pace and duo bMGNKs me d <br />.14140 TAM' I► <br />20 DID TOBACCO <br />X 1 <br />E ONTRIDUTE k H' DEATH? <br />USE C <br />YES El. NO ❑ UNKNOWN <br />3111 HAS ORGAN OR TISSUE DONATION BEEN EN CONSIDERED? <br />al YES ® ND <br />3011 WAS CONSENT GRANTED? <br />x"- ❑ YES CA NO <br />31- NAME AND ADDRESS OF CERTIBE* IPHYSICUW. CORONERS PHYSICIAN OR COUNTY ATTORNEY' 1Typit ea Pull <br />* Dr. Larry Han en, M.D., 30 6 W. Faidley Ave., Grand Island, NE 68803 <br />32a REGISTRAR <br />i <br />3211 DATE FILED BY REGISTRAR IBIO.. Day WI <br />SEP1 52004 <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL Tfd -AND <br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON <br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES,- VIF14'L•RECORO$ <br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE I td <br />7/28/2011 <br />LINCOLN, NEBRASKA <br />STATE OF NEBRASKA <br />201 <br />TH <br />201100299 <br />STANLEY IJCOOPER <br />fSSISTANT STATE REGISTRARR' <br />DE'PARTM.E"NT OF HEALTH AN, D <br />HUMAN RVLCES <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND, SUPP(IR' <br />VITAL STATIST= <br />04 10043 <br />