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t DECEDENT -NAME FIRST MIDDLE UST <br />M arga re t Edna Beragren <br />2 SEX <br />Female <br />3 DATE OF DEATH Wawa Dap rue <br />September 27, 2004 <br />4 CITY AND STATE OF EARTH nen.r 6ow. w <br />Chadron, Nebraska <br />91 AGE • Laet UNDER t YEAR <br />UNDER 1 DAY <br />6. DATE OF &RTN, #ANRR. Oar Veal <br />October 6, 1925 <br />Ms 1 50 MOS I DAYS <br />78 <br />Sc. HOURS MISS <br />Z 7 SOCIAL SECURTIY NUMBER <br />0 506-20 -4123 <br />S. PL OF DEATH <br />HOSPITAL + OTHER . NIF9rtg homy <br />U 80 FACILITY - Name ! / nd e,TaMe6rc yi»aMee/ <br />o Good Samaritan Hospital <br />1 ER POOR* III <br />III 00A ❑ <br />Readence <br />oft, /spec", <br />6c CITY TOWN OR LOCATION OF DEATH 1 Ed INSIDE CITY LIMITS <br />Keamey I yes ri No ■ <br />6e COUNTY OF MEATH <br />Buffalo <br />Sc RESIDENCE - STATE <br />Nebraska <br />CO PACE - Ng., WNW Boca Ameneen <br />mel ISppe y, White <br />Sc COUNTY <br />Hall <br />maw It ANCESTRY leg Wien, Mee¢M1 <br />1 I MO GermarllEnglish <br />Sc CITYMIWN OR LOCATION <br />Grand <br />Glancy we <br />Island <br />tP E2 MARRIED <br />I I NE,rtR <br />F n <br />S6. STREET AND NUMBER <br />2317 Pioneer <br />. WIDOWED <br />I I DIVORCED <br />ana1WplpCOAN <br />Blvd. 68801 <br />13 NAME OF SPOUSE re IRAs 9Wnyipin <br />Myron <br />yron Berggren <br />9e9e INSI L MITSCRV <br />Va. !� NO ❑ <br />MOW <br />14. a/work ate. en 'ION IGn6M6ol,tweuwaT,InD,Ryr <br />ateoTeM3ra a1* wedl <br />Vice President <br />110 KMDOFBUSSIESSIIDUSTtry <br />Food Service <br />15 EDUCATION ISpaebogyNplURBntleCenglab6l <br />EM y aYT a Samoan 11).121 C9W3e ), i a e• <br />16 FATHER .NAME FRS' WODLE LAST <br />F. Harry Williams <br />,7 MOTHER FIRST M100 MAIDEN SURNAME <br />Edna C. Hammond <br />10 WAS DECEASED <br />(Yee no Or Eaetl 1 <br />NO <br />EVER IN US ARMED FORCES? <br />f6 yes CPA WIRY 6wFNWNle ( <br />,9a INFORMMNT - NAME <br />Myron Berggren <br />190 INFORMANT MAIUNGADORE55 STREET O a RF 0 NO. CRY OR TOWN STATE Z R <br />2317 Pioneer Blvd. Grand Island, Nebra 68803 <br />2a EMBALMER - TURE 6 ! y ` .✓ <br />A � <br />P MET 000E OWPD <br />cg.,.... o R..... <br />2t0 DATE 7 SIC CEMETERY OR CREMATORY NAME <br />Sep 30, 2004 I Grand Island City Cemetery <br />22a FUNERAL ROME • NAME <br />Apfel- Butler- Geddes Funeral Home <br />■ Darrow ■ Dewier <br />216 CEMETERY OR CREMATORY LOCATION C.TY OR TOWN STATE <br />Grand Island, Nebraska 68801 <br />220 FUNERAL HOME ADDRESS (STREET OR R F 0 NO CITY OR TOWN STATE. ZIP( <br />1123 W. 2nd St. Grand Island, Nebraska 68801 <br />23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR ■al Obi. *Wag kennel Mween onset anc 6eMn <br />PART �{ Q� 21 N 5 t VC:: <br />lai Y cGfzE is c_ (31._e a D 5 abuk5 <br />DUE TO. OR AS A CONSEQUENCE OF <br />VOW ABSEInn onset WA dea> <br />MI ST# ( � �' <br />(R-&t— l?tA9c Y (S) I6 ( o UliS <br />J\` <br />DUE TO OR AS A CONSEQUENCE OF <br />UNc rAbl.toab H4 pe- ---TE, Ns LI f� . Y�M�e..n 6n..ta��a� <br />011 Il <br />ip ..el Ma <br />PART OTHER SIGNIFICANT CONDITIONS - Ce dAw. coWI�lg b I MINNOW <br />A <br />PART Al IF FEMALE. WAS THERE A <br />PREGNANCY IN THE PAST 3 MONTHS? <br />MOW 10 -540 VW Fl NO 2r <br />24 AUTOPSY <br />WA ❑ No r <br />25 WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER, <br />Yes T] No <br />28a <br />r ACCdN 0 um...„.... <br />0 Se A. II Findn <br />HPINtde mYeelgMpn <br />27. <br />25b DATE OF INJURY Ab OW t21 <br />26c HOUR OF INJURY <br />266. DESCRIBE HOW INJURY OCCURRED <br />26e INJURY AT WORK 261 QQF,�py 0 07 Wm FPAM lANCe <br />0{M6HS elC (3OeL'AY/ <br />Yq • ND • <br />263 LOCATION STREET OR CF0 NO CITY CRIMP" STATE <br />W <br />1 DATE OF DEATH IAtd Day VT; <br />a s September 27, 2004 <br />< > <br />li S <br />t > <br />at <br />to a <br />d <br />2$. DATE SIGNED Mb DIY W 1 <br />2E0 TIME OF DEATH <br />E <br />` <br />29 DID TOBACCO <br />?7D DATE SIGNED 0.4) OW Yr, <br />Oc _ o l+ <br />270 1 0M0NIa9191024•099919121 eaa1M <br />Plc TIE OF DEATH <br />0 4 -.. M- t- �M <br />.6MeaneMaeeMMd.ebel. <br />21c PRONOUNCED DEAD Mb Dap Yi) <br />M <br />216 PRONOUNCED DEAD aa <br />woe, <br />M <br />CaesHS)leted <br />iS�gnAure and T6.) la > <br />2•• On ele bus aeaelwlaaetlald � tTeen octane"" <br />S We AMA dMB.WI Om and Sus b MI Ca;RR6NOM <br />, (SCAN... and Taal P <br />USE CONTRIBUTE TO THE DEATH. 1 3Lta HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 302 WAS CONSENT GRANTED> Ike d <br />YES NO UNKNOWN I 0 YES I'rr NO i YES J'N NC �e <br />31 NAME AND ADDRESS OF C " • <br />CERTIFIER IPHYSICIAN. CORONER5 PHYSICIAN OR COUNTY ATTORNEY) Ingo ••Rettl <br />Andrew Saw M.D. 11 East 31st St., Kearney, NE 68847 <br />32a REGISTRAR <br />Aerie I r M <br />BY REGISTRAR IAb DaY V, I <br />32D DATE FILED ncT d ,rw <br />STATE OF NEBRASKA <br />197 <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH 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, VITAL RECORDS <br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. STANLEY OOPER <br />201306834 ASSISTANTSTSTAT E REGISTRAR <br />DEPARTMENT OF HEALTH AND <br />HUMAN SERVICES <br />STATE Of NEBRASKA - DEPARTMENT OF HERON AND HUMAN SERVICES F NAfdRE AND SUPPORT <br />VITAL MAMMIES <br />CERTIFICATE OF DEATH <br />DATE OF ISSUANCE <br />JUL 12 2013 <br />LINCOLN, NEBRASKA <br />TAM" • •.••• • , ..— - - -- - --- .. -- <br />04 <br />10737 <br />