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132a
<br />DUE TO. OR ASATFICE OFD
<br />O.
<br />PL/,a 4-de ..z alb
<br />AS A
<br />PRAT OTHER SEINIFICANT CONDOMS • Condemn Cd141Ix1*ing Io OHO but not
<br />DATE OF ISSUANCE
<br />JUN 212013
<br />LINCOLN, NEBRASKA
<br />HE DEATH?
<br />11*
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF (WEALTH AND
<br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE'ORIGINA(t'RECQR•U,ON
<br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, 'VITAL. RECORQS
<br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />201305279
<br />!MATE OF DPARTNIUNT OF KAM
<br />IlLINFAU OIL VTF* . STATI$IIcS , r....
<br />CERTIFICATE OE D &Th - ,
<br />} 2. SEX
<br />2n. MURAL CferitH on.Raewook
<br />Donlon
<br />Cremation
<br />2SLb, DATE
<br />Nov. 23, 1993
<br />- STATE
<br />Nebraska
<br />1 t UMRRIED,NEVER MAAAIED,
<br />\C7 VADO*EQ DIVORCED (S Y1
<br />German /En fish Married
<br />144. USUAL OCCUPATION (Oiw hind W rant mans soft l e@. atiND MESS Mt.
<br />Of al two* r NARK.
<br />1Q RACE • pB.}. WPM, Sack Ammtent InElat 11. ANCESTWI SWANK MOW,
<br />am) lEMNOW
<br />White
<br />DI. COUNTY
<br />Hall
<br />Farmer `'`. A ricultur
<br />LAST FT. MO
<br />Fredrich Wilhelm Theodore Hodtwal
<br />It FATHER • NAME
<br />DUE
<br />S<L a* IATURE i UCENSE
<br />2Aa. DID TOSACCO 002 CON
<br />MAST MIDDLE
<br />It WAS DECEASED EVER IN U. AIWED FORCES?
<br />MN. no. a arks! to d a m s$
<br />Not Embalmed
<br />•
<br />w
<br />74
<br />2 GATE 0 DEATH Roo, Day. Y,.(
<br />/zZ
<br />270. DATE SIGNED 1410. Day. VI.J 17e. TIME OL' DEATH
<br />J 2. 3 !q
<br />27d. To Put Dent of my tnowwdpe. dean at as t. min EP
<br />Am
<br />T
<br />22
<br />HAS •;: <
<br />101St
<br />Sc l - ; $ 1'fe < ^s - Ali
<br />PART PI IF FEMALE. WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />Yet o No C
<br />STREET ANO women iningey
<br />110 East 22nd
<br />Eiomay or
<br />asd Tool
<br />24. AUTOPSY
<br />Smeoly Yes a MN
<br />r./
<br />10+12} i 040l3.}
<br />PRONOUNCED DEAD (Mdse
<br />1 Hw
<br />On Nre bows of axaminairon and %oatmgon. in my 004+41+ 41Mh oocuI*d ai
<br />24, dam ono Orate u11(1
<br />and duo to mo es} moot
<br />la
<br />Donald Dean Hodtwalker ' Male
<br />f. ATE r� aqf i1 . mii r iM/Jl � &41 • I,MM s l' r », ty
<br />(wsJ w 7 ia I 1 t�IMS4
<br />Crete, Nebraska 63 1
<br />01. SEA
<br />... /OEM 0 ERKI wr o DDA
<br />507 -48 -5544 Q Hales o Reklenaa O carer (*.MO
<br />AEIL�PY • Pima
<br />it rirErlat Op ,rr. alrmaf1+14 Oa OTT, T�MM CR OEAl10a1 Obi a" Es 41010E UNITS
<br />LTS
<br />law*
<br />St. Francis Medical Center Grand Island, Nebraska Yes
<br />TOWN LOCATION
<br />Grand Island, Ne.
<br />THAR • MA1O2N NAIL
<br />MAO YES 0 NO UNKNOWN YES 0 NO
<br />31. NAME O ADDRESS OF CERTIFIER (PHYStCAN. CORONER'S PHYSICAN OR COUNTY ATTOi1N2V (Type a PnnE ~�
<br />;STANLEY 5{ICOOPER • , ,,
<br />ASSISTANT ST4TE I3EG1STRAR
<br />`DEPARTMENT OF HEALTF+AND
<br />HOMAN-SERVICES,.
<br />93,,.:J3173
<br />July
<br />3. DATE OF DEAIMr pa: Yaari "`
<br />�r 22, 1993
<br />RTH NMarR D Ynf1
<br />1, 1930
<br />E4. COUNTY DEAT _
<br />Hall
<br />np craw is. i ai nreofi
<br />(S4' * 7Y! iru M Nqt
<br />NAkiE OF SPDU# Nl 0 -
<br />n1+1tdn n )
<br />Jo ce Roach
<br />MIDDLE
<br />ker Mary LuEllen Park
<br />LFtFOG�fAA,NT - IFAMAE • tJiAI.3NC3 ADDRESS IS OR R.F.D. NO., QTY OR TOWN, STATE, 1 8801
<br />o ce Hodtwaikr 110 E. 22nd Grand Island Ne.
<br />TE:RY OR CREMATORY SANE 20d. LOCATION CITY OR TOWN STATE
<br />Central Ne. Cremation Ser. Gibbon, Nebraska
<br />F UNERAL HOME •NAME 4J #1 ADDRESS 151.4EET OR RF D . ND.. CITY OR TCJAI, STATE. 21P} b880 1
<br />ivin•ston- Sondermann 505 W. Koeni. G a d Island. Ne.
<br />CAUSE ma LINE FOR t11, (D). RN0 tir}1 I don* Se41IW1 oast and OM
<br />23. IMMEDIATE /i C , A , LI , ' � i / 1
<br />PART
<br />X g te= a lp riLk L.s • f� ? /�r' d 3 # Lyvt S4 (C c.4g �Jc r! + tii4.ir: hid;
<br />1 LL..............-
<br />r" 1 Iniswol Wow HMO and cleat
<br />AO1;l0ENT SIAGDE, Shit.! :J?E, UNDET.. M0. CATE OF INJURY (mitt -Da Yr) Mo. HOUR OF INJURY 214. DESCReE HOW INJURY OCCURRED
<br />OR PENOMD W VESTIG, , *' , . - . ISPootr
<br />29s. INJURY AT WORK 2d. PLACE OF INJURY • At home. Wm. *cost Nottry. f 2130. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />( Yee a Mod } *Soo Dwarfing, eN. (simeR
<br />TISSUE 4044 TICN 05224 CONSZE.
<br />2Sa. DATE 0ADNSD ,RHO Yrl 199. TIME OF DEATH
<br />PRONOUNCED DEAD (Ofd.. 411 .
<br />31 D. WAS CONSENT GRANTED,
<br />❑ YES
<br />1 32o DATE FILED SE IR M/ Y,,
<br />Yes
<br />Ileatval brew awl 4114 ONE
<br />21. WAS CASE REFERRED TO MEDICAL
<br />FUSSIER OR 00*1O ER?
<br />Moor* Yoe or Nogr
<br />
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