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STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 354510
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS-NAME (First, Middle, Last, SuMx) 2. SEX 3. DATE OF DEATH (Mo.,Day,Yr•)
<br />PI
<br />Lester Francis Stecker
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Culbertson, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505 -20 -6939
<br />86. FACILITY -NAME (Knot institution, give street and number)
<br />Life Care Center of Elkhorn
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68022
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />105 E. 22nd St
<br />10a. MARITAL STATUS AT TIME OF DEATH : ❑ Marred ❑ Never Married 19b. NAME OF SPOUSE (First Middle, Last Sumx) if wife, give maiden name.
<br />❑ Marled, but separated ® Widowed ❑ Divorced ❑ Unknown Lola Burr
<br />11. FATHER'S -NAME (Flint Meddle, Last Suffix)
<br />Tjark Stecker
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yee, No. orUnic) Yes 02/25/1943- 02/03/1
<br />I8. METHOD OF DISPOSITION
<br />'Pedal ❑Donlan
<br />❑ CmnaWn ❑Emompsem
<br />❑ Ranovd 00th.1t padM
<br />17e. FUNERAL HOME NAME AND MAIIJNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART t Enteral ebain erswa.- dewss. 1Nuda, er complication-that airway caused the Warn. DO NOT linter Jemmied events such ma cardiac arrant.
<br />mepimo y anal, drvsnMeukrltbd9dbn wahoet chewingth wader* DO NOT ABBREVIATE. Enter esiyane caws en a We. Add additional lines if nscaasery.
<br />IMMEDIATE CAUSE:
<br />MEDIATE or CAUSE (Final a
<br />disease or condition resulting a) L
<br />In death) D
<br />Sequentially Ilst conditions, I
<br />any, loading M the cause need bl
<br />on line a.
<br />3/ c
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />9b. COUNTY
<br />Hall
<br />18e. EMBA , TU
<br />18d. CEMETERY, - • RY OR OTHER LOCATION CITYITOWN STATE
<br />Westlawn Cemetery Grand Island Nebraska
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />u---4-;k. ASb S
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that initiated
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />d)
<br />5.. AGE -Last Birthday
<br />r
<br />92
<br />14a. INFORMANT -NAME
<br />Jam =, - C = . Stecker
<br />18. PART 11.OTHER SIGNIFICANT CONDmONS- Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />M-r -) ie �a �a-y� A 6I D■CkeVQ∎r" - 4:4 1 D e-,4"
<br />21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY
<br />*Natural ❑ Homicide ❑ DdveHOperator
<br />❑ Accident ❑ Pending Instigation ❑ Passenger
<br />❑ Suicide ❑ Could not be determined ❑ Pedestrian
<br />❑ Other (Specify)
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑Not pregnant, but pregnant 43 days to 1 year before death
<br />❑Unknown H pregnant within the past year
<br />22a. DATE OF INJURY (Mo.. Day, Yr.) 122b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />m
<br />22d. INJURY AT WORK?
<br />I 22e. DESCRIBE HOW INJURY OCCURRED
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER APT. NO. „ CITY/TOWN
<br />23a. DATE OF DEATH (Mo.,Dpy, Yr.) ;.__ .
<br />23c. TIME OF ¢PATH
<br />S 4( m
<br />S '-
<br />t
<br />23d. To the test of my Iyi wledge, de - cured at the time, date and place
<br />d due the ea is) stated. ; n - .i • Title)
<br />27. NIIE, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />28a. REGISTRAR'S SIGNATURE
<br />o
<br />8a. PLACE OF DEATH
<br />19:991191.; 0 Inpatient
<br />❑ ERlOulpatient
<br />9c. CITY OR TOWN
<br />Grand Island
<br />12. MOTHER'S -NAME (Flrat, Middle, Maiden summit)
<br />Kate Jelken
<br />41. UNDER f YEAR
<br />MOS.
<br />DAYS
<br />9.. APT. NO.
<br />Male
<br />❑ DOA ❑otlter(Specly)
<br />17.
<br />5c. UNDER 1 DAY
<br />HOURS
<br />8d. COUNTY OF DEATH
<br />Douglas
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />USE CONTRIBUTE TO THE En ` ' UO HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 Q PROBABLY' b[ UNKNOWN p ❑YES ,�NO
<br />MINS.
<br />91. ZIP CODE
<br />68801
<br />24c. PRONOUNCED DEAD (Mo.. Day, Yr.)
<br />March 12, 2014
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />July 14, 1921
<br />raFFMIN Nursing Home/LTC ❑ Hospice Facility
<br />❑ Decedents Hone
<br />9g. INSIDE CITY LIMITS
<br />® Yes 0 No
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />18c. DATE (Mo., Day, Yr.)
<br />March 17, 2014
<br />onset to death
<br />onset to deathv
<br />onset to death
<br />24b. TIME OF DEATH
<br />201402911
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES /y NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES 0 N
<br />STATE ZIP CODE
<br />2Ad. TIME PRONOUNCED DEAD •
<br />m
<br />m
<br />24s. On the basis of examination and/or investigation, In my opinion death occurred
<br />at the time, date and place and due to the cause(s) stated. (Signature and Titie)
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a is NO ❑ YES ❑ NO
<br />28b. DATE FILED BY(REGISTRAR (Mo., Day, Yr.)
<br />MAR 26 2014
<br />This certifies this document to be a true copy of an original record on file with Vital Statistics, Douglas
<br />County Health Dept, Omaha, Nebraska. Certified copies must have a raised seal in the area to the left.
<br />Reproduction of this green cettificate are not legal copies.
<br />MAR 262014
<br />Date Issued: Registrar:
<br />
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