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1.OECEDENr S.N*NE :(Fink MidMa,.``. Last, Mall ly
<br />Harold Herman Kuck
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH .)
<br />July 26, 2013
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Worms, Nebraska
<br />S AGE -Lad Birthday
<br />(Ys.)
<br />87 >
<br />M. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />:. 0. DATE OF. BIRTH (Mo., Day, Yr.)
<br />October 12, 1925
<br />MOS.
<br />DAYS
<br />HOURS S
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />1 506-32 -7918
<br />S.. PLACE OF DEATH
<br />H 1n ant QT,gg; ❑ Nursing Nome/LTC ❑ Hawks FadlNy
<br />❑ EWOunatlsm : : . : 0 DacedwIrs" me
<br />cIfy
<br />❑ °0A ❑ )
<br />8b.: FACILITY- NAME (N not hatlbrtlon, give OUR and :number)
<br />Veterans Affairs Medical Center
<br />Ec. CITY OR TOWN OF DEATh (10CIud. hp Cod.)
<br />Grand Island 68803
<br />`e .COUNTYOFDEATH
<br />Hall
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />Sb. COUNTY
<br />Hall
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />04. STREET *240 NUNEER :
<br />831 East Delaware Avenue
<br />as. APT. NO.
<br />00. ZIP CODE..
<br />68801
<br />9g. INSIDE CITY UNITS
<br />E Y« 0 No
<br />101. MARITAL STATUS AT TIME OF DEATH laMaried ❑ Now
<br />Q Mauled, but separated ❑ Widowed ❑ Divorced.'' ❑ Unknown
<br />1044. NAME OF SPOUSE (First, M1aw. Last, SuM)x)1/ wife, gide maiden name
<br />Rose Aurora Ehn
<br />11. :FATHERTS -NAME (Fist, Middle, :Last, SWIM)
<br />Herman Kuck
<br />12. MOTHER'SNAAE (Prat. Middle, Maiden Surname)
<br />Katie PMichelsen
<br />13. EVER IN U.S. ARMED FORCES? Give dates of sondes if Yes.
<br />(Y•. No, or Yna) Yes 07/23/1945- 12/04/1945
<br />14a. INFORMANT -NAME
<br />Rose Aurora Kuck :
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16. METHOD OF DISPOSITION
<br />Mamma ❑
<br />Dominion ElEntombnunt
<br />❑ rte ❑orh•t• -n
<br />EMBALMER ii ii ��~~
<br />� iiii
<br />16b. LICENSE NO.
<br />/c 7/
<br />111c. DATE (Mo., Day, Yr.)
<br />July 30, 2013
<br />18d CEMETERY, CREMATORYOR OTHER LOCATION» CITY/TOWN STATE
<br />Zion Lutheran Cemetery Worms Nebraska
<br />17.. FUNERAL HOME NAME AN0 MAIUNG ADDRESS (Sbsat, City ar Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b: Zlp Cod.
<br />8880
<br />CAUSE OF DEATH (See instructions
<br />and examples)
<br />as wan *ad = APPROXIMATE INTERVAL
<br />additional Knee IF neer..7.
<br />: onset to death
<br />e.
<br />1.. PART I. anrraf serifd.w agues. 1061001011..U0 afoul* mums the dMIII. DO NOT ender tannin. .wAspun
<br />mpm1y amid, rwrm*eWr 9Cnhao.n without .lowing Ms edobpy. DO NOT AO911LNIATL:.mw only ono cane on a kw::Add
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />disunites condition ssuPolp a) /[''�' y �r�( 1
<br />In death) `IA t (to P `t .� c s - r 1 ` \�
<br />DUE TO, OR AS A CONSEQUENCE OF: 1 onset TO death
<br />Sequentially Ilat conditions, S
<br />any, leading to the cause dated. b) C c� \ (\ 'N %
<br />"
<br />on Ens. a.. DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE: 11 ` ♦ \
<br />(dI orKluryMNd initiated s' ® ® "� St 0 \
<br />: onset° daub
<br />0 _ s
<br />\ . onset to dotal
<br />th the m,. Ne me th , theme) : DUE TO, OR AS A CONSEQUENCE OF: ..,
<br />LAST
<br />d)
<br />18. PART I4 OTHER SIGNIFICANT CONOITIONS.CondNbM conblbutlnp to Ilse dnatll but rats $t tlng In the uYgMying cane given In PART 1.
<br />Mr 0., i AQ�
<br />• \d t1 Q..\\_ ASLLC c\c‘ei ` e-
<br />it WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ' No
<br />28.1E FEMALE: )
<br />❑Not pregnant within pant year
<br />❑hpn.nt at time Mama
<br />❑Nat pregnant, but pregnant wit/du 42 days oldeMh
<br />ONO pr.Pnam, but pregnant W days to 1 year before death
<br />©Unknown N pregnant wlWn Meted year
<br />21a. MANNlR OF DEATH 1\
<br />Hmld
<br />od.
<br />❑ Accord ❑ Pending kivestgellon
<br />ned
<br />❑ Suicide ❑ Cads' not bra determined
<br />216. IF TRANSPORTATION INJURY
<br />❑ lNIveROper ter
<br />❑ Passenger
<br />Pedestrian
<br />❑ Other (SP•ahl
<br />210. WAS AN AUTOPSY D?
<br />0 YES o f ERFORME
<br />21d. WERE LETEY FINDINGS AVAILABLE
<br />TO Y EMS1PLEr! SE OF DEATH?
<br />❑ YES No
<br />22a DATE OF INJURY 1Mo., Day. Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22e. PLACE OF INJURY- Athont., firm, bleat, factory, Mk* building, oon.tnrcSon site, ek.:ISP•clry)
<br />22d. INJURY AT WORK?
<br />YES 0 N
<br />22e. DESCRIEE NOW INJURY OCCURRED
<br />72I. LOCATION OF INJURY- STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />N'
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED .(00., Day, Yr.)
<br />- ® C:i1
<br />24b. 1121E OF DEATH
<br />m
<br />276. DATE ED (Ma, Day, Yr.)
<br />o
<br />qZ
<br />230.110! OF DEATH I i O 24c. PRONOUNCED DEAD (Mo., Oey, Yr.)
<br />P
<br />24d. THE PRONOUNCED DEAD
<br />224. To
<br />cry(
<br />of illy :door ocuunud at the Una, data and pleas t+
<br />So the eau 0) . Signature and Tltly
<br />IS
<br />24e. On the basis of emmirwtl hl
<br />on .ndlorv.W (n rip/ rips opinion rre
<br />don death oca d
<br />et Sirs timk data and place and due to the cause(s) stated. (Signature and Ilea)
<br />25. DID TOBACCO ... • B TO THE DEATH? :-.._..
<br />❑YES DUO. ' 'a - • LY 0 UNKNOWN
<br />HAS ORGAN OR Tissue DONATION BEEN CONSIDERED?
<br />0 YES - NO
<br />: 26b. WAS CONSENT GRANTED?
<br />Not Applicable II 211. In NO ❑ YRS L N0
<br />27. NAME. TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />c ' 1(1C1U \e\II k YAcM 1 PCBLA5N (r'arck
<br />c\skp(a f Phcrx,`fa to C
<br />26a. RE TRANS SIGNATURE : DATE FILED BY REGISTRAR (Moe Day, Yr.)
<br />t 2Eb .
<br />AAA • AUG 72013
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND..HOMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />08/09/2013
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />20/406463
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />`:'RCDTICIPATC( AG' RE.ATLJ
<br />STANLEY S _COOPER
<br />ASSISTANT STATE REGISTRAR, '
<br />DEPAOTMENT OF HEALTH AND
<br />HUMAN SERVICES
<br />
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