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2.82
<br />201407057
<br />1 , Y ‘y
<br />This certifi d this document, tit be a true copy of an original record on file
<br />with the Vital Statiiirt+cts Section' of the Douglas County Health Department,
<br />Omaha, Nebraska. Certifie4 copies must have a raised seal in the area to the
<br />left. Reproductions 0i °this green certificate are not legal copies).
<br />•
<br />Q, -I; ,V.
<br />Z2,;,„PY
<br />_
<br />Date issued. DANA 1.' ig89
<br />DOUGLAS COUNTY HEALTH DEPARTMENT
<br />Vital Statistics Section
<br />OMAHA, NEBRASKA
<br />CERTIFICATE OF DEATH
<br />(Registrar)
<br />243139
<br />DECEDENT -NAME FIRST MIDDLE- LAST
<br />1. Theresa Lorraine Bj_ornberg
<br />I SEX DATE OF DEATH (M° , U. Yr )
<br />I
<br />2 Female 3 January 8 8,_1989 _ _ ____
<br />RACE- (e.g., White, Block, American
<br />Indian, •tc.) (Specify)
<br />4. White -
<br />ORI GIN /DESCENT (e.g., Italian, Me I AGE -Lour Birthd
<br />German, etc )(Specify) i (Yrs.)
<br />5. American 16a 68
<br />UNDER 1 YEAR UNDER 1 DAY DATE OF BIRTH (Mo , Doy, Yr )
<br />MOS. . DAYS HOURS • MINS
<br />6b. .a< •
<br />7 February 1, 1920
<br />Z' '
<br />W
<br />Q.
<br />•
<br />CITY AND STATE OF BIRTH (If ne. in U.S.A.,
<br />nome country)
<br />B. Omaha, Nebraska
<br />CITIZEN OF WHAT COUNTRY MARRIED, NEVER MARRIED, NAME OF SPOUSE (11..f.. gi•e mo,d.n nome)
<br />'WIDOWED, DIVORCED (Specify)
<br />U.S. 9 to Married 111 Carl A. Bjornberg
<br />SOCIAL SECURITY NUMBER
<br />12 506 -16 -7370
<br />USUAL OCCUPATION (Give kind of work done during most
<br />o / wor k ing life, even if refired)
<br />13a Housewife
<br />KIND OF BUSINESS OR INDUSTRY
<br />I)b At Home
<br />L
<br />I COUNTY OF DEATH
<br />LI4o Douglas
<br />CITY, TOWN OR LOCATION OF DEATH
<br />lib. Omaha
<br />INSIDE CITY LIMITS
<br />(Specify Yes or No)
<br />14c.
<br />_
<br />HOSPITAL OR OTHER INSTITUTION - Nam. (If not in e,th•r, TIT HOSP OR INST Indicate DOA.
<br />give street and number) ourpm ;en. ;Em.c Ern Inpon.ne (Spec,Fy)
<br />( 14d Clarkson Hospital 114. Inpatient
<br />RESIDENCE -STATE
<br />1sa. Nebraska
<br />_yes
<br />COUNTY
<br />lsb. Hall
<br />CITY, TOWN OR LOCATION
<br />is, Grand Island
<br />_
<br />STREET AND NUMBER
<br />115d 306 East 20th Street
<br />1 INSIDE CITY LIMITS
<br />(Specify Yes or No)
<br />1s. es
<br />P"'
<br />2
<br />W
<br />FA HER - NAME FIRS MIDDLE LAST
<br />16. Carl E. Swanson
<br />1 MOTHER- MAIDEN NAME FIRST MIDDLE LA
<br />1
<br />,,. Lydia Johnson
<br />�`
<br />CC.
<br />,F.'
<br />W
<br />Ll
<br />WAS DECEASED
<br />(Yes, no. or unk)
<br />- B. no
<br />EVER IN U.S. ARMED FORCES4 1
<br />(11 yes, give .e, and dotes of service) -
<br />(
<br />INFORMANT- NAME - RELATIONSHIP -- MAILING ADDRESS /� (STREET OR 81 0 NO. CIT' OR TOWN. STATE. ZIP)
<br />30 fT East_ 2Qth Street
<br />19. Carl A. Blomberg husband, Grand Tslan d, N 6
<br />BURIAL, Cremation,
<br />oo. Burial
<br />Removal) DATE
<br />j2ob. 1/11/89
<br />CEMETERY OR CREMATORY - NAME
<br />204. Forest Lawn Cemetery I2od.
<br />LOCATION CITY OR TOWN STATE
<br />Omaha, Nebraska
<br />EMBALMER-SIGNATURE & LICENSE NO.
<br />Ls/ R.J. Wessling 2355
<br />FUNERAL HOME -NAME AND ADDRESS (STREET OR R F 0 NO , CITY OR TOWN. STATE. ZIP1
<br />22 Roeder Mortuary 2727 North 108th St.Omaha,Ne.68134
<br />T. M ComplN.d by
<br />AM.nding PHYSICIAN
<br />Only
<br />DATE OF DEATH (Mo., Day, Yr.)
<br />23a. 1-8-89
<br />1 z>
<br />I HO
<br />=C
<br />� aZe
<br />1 160
<br />�R m O V
<br />V o
<br />DATE SIGNED (Mo. Doy, Yr.) ; HOUR OF DEATH
<br />240. 24b. M
<br />DATE SIGNED (Mo., Day, Yr.)
<br />231E. 1 - 10 -89
<br />HOUR OF DEATH
<br />11 : 00 A
<br />23c. M
<br />PRONOUNCED DEAD I PRONOUNCED DEAD (Hour)
<br />(MO., Day, Yr.)
<br />2 4c. L24d. M
<br />To the best of my knowledg., death occurred of the time data and ploce and du• to the
<br />sous.(*) stated.
<br />23d. (Signotur. and Title) ► / s / Randal S. Castling , MD
<br />On eh• boils of •.ominatton a nd/or in.estigot;en. to my op.nion d•oth occurred of
<br />the lime, do • and plat• and 4.• to the cause(*) stated
<br />240. (Signature and I;nc ►
<br />U.1
<br />to
<br />Q'.
<br />U
<br />NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />25 Randal S. Cassling, M.D. 465 Drs' Bldg Omaha,NE
<br />REGISTRAR ^ � 4. � f )� : .� ) / i DATE R ECEIVED BY REGISTRAR (Mo . Doy. YrJ
<br />26a.(Signatur.) ./' / �PriC3,�/ /'J - �, = L� . , , r ' . = % . P • i • JAN 1 3 193
<br />'266
<br />27. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINEJFOR (o), (b), AND (c)1 . Inter.al bet..•n onset and depth
<br />PART
<br />I,, Renal failure
<br />DUE TO, OR AS A CONSEQUENCE OF: lnter.al b.t..•n. onset and depth
<br />(b) Congestive heart failure
<br />DUE TO, OR AS A CONSEQUENCE OF: . Int..va1 b.n.e.n onset and death
<br />(c) '
<br />PART OTHER SIGNIFKANT CONDITIONS - Conditions contributing to death but not related
<br />11
<br />PART 111 IF FEMALE, WAS THERE A i AUTOPSY
<br />PREGNANCY IN THE PAST 3 MONTHS? ; ISp•uf, Yes or No)
<br />I
<br />Yes D No 28 no
<br />WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER
<br />(Specify Y.s nr No)
<br />129 nO
<br />ACCIDENT. SUICIDE, HOMICIDE, UNDET.,
<br />OR PENDING INVESTIGATION. (Specify)
<br />300. .. _.. >.._..........3
<br />DATE OF INJURY (Mo., Doy, Tr.)
<br />_.....
<br />HOUR OF INJURY
<br />30c. M
<br />DESCRIBE HOW INJURY OCCURRED
<br />30d.
<br />INJURY AT WORK
<br />(Sp.<ily Yes or No)
<br />30..
<br />PLACE OF NAM- At ho,.., tom, street, factory, LOCATION STREET OR R F D. No. CITY OR TOWN STATE
<br />office bedding, • e. (Sp•cily) I
<br />30f. (309.
<br />2.82
<br />201407057
<br />1 , Y ‘y
<br />This certifi d this document, tit be a true copy of an original record on file
<br />with the Vital Statiiirt+cts Section' of the Douglas County Health Department,
<br />Omaha, Nebraska. Certifie4 copies must have a raised seal in the area to the
<br />left. Reproductions 0i °this green certificate are not legal copies).
<br />•
<br />Q, -I; ,V.
<br />Z2,;,„PY
<br />_
<br />Date issued. DANA 1.' ig89
<br />DOUGLAS COUNTY HEALTH DEPARTMENT
<br />Vital Statistics Section
<br />OMAHA, NEBRASKA
<br />CERTIFICATE OF DEATH
<br />(Registrar)
<br />243139
<br />
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