|
�
<br /> S1/2 SW1/4 of 17-12-11, Hall County, Nebraska
<br /> WF�N TH/S COPY CARfZ�S THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN 3�3_
<br /> SYSTEII�IT CERTIFIES TF�BELOW TO BE A TRUE COPY OF THE OR/GINAL RECOR4Q�'FA�JN�
<br /> THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEII�VITAL STATIST/CS SE� ' � �-'��--:
<br /> THE LEOAL DEPOS/TORYF�It VITAL RECO� �,;,���
<br /> DATEOF133UANCE � � -
<br /> _�_ - - �
<br /> r��1��4'��S��PN�€Y�sf'�_: =� ='
<br /> DEC 3 1999 2 0 0 0 0 0 2 8 0 ,,SS,Sr„���,�;s�. .-�_=
<br /> UNCOLN,NE9RASKA HEALTH AND H!lMAN��SY$i�/,t` _=
<br /> STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVIC�TG��UP�RT
<br /> VITAL STATISTICS
<br /> CERTIFICATE OF DEATH M'�"-��� �2 2 3 2
<br /> 7.DECEDEN7-NAME FIFST MIDDCE IAST 2.SEX 3.DATE OF DEATH lMon(h,Oey,Yavil �
<br /> M rtle Emil Ummel Female Februar 21 1999
<br /> 4.CI7V AND STATE OF BIflTH-/if mt M U.S.A.,�me rnunrryl 5a.AGE-Last Birthday UNDEH 1 VEAH UN�ER 1 DAV 8.DAiE OF BIRTH lMontry,Dsy,Ymil � �
<br /> Brid e ort Nebraska ��""� �� 5b.MOS. I DAVS Sc.HOU(iS I MINS.
<br /> Januar 26 �922
<br /> 7.SOCIAL SECUNITV NUMBffl ee.PLACE OF DEA7H ------��--
<br /> S2O'2O'OYVO , HOSPoTAL:��[ient OTMEA: �NuninpHome
<br /> e�.FACILI7V-Name . /it rat insNtufbn,yive srreet siM nwMal �ER Outpatlent �fleeidence
<br /> St. Francis Skilled Caze ❑ooA ❑a�„e,,s�,�,
<br /> ec.CI7V,TOWN OR LOCATION OF OEATH 8d.INSIDE CITV LIMITS 8e.COUNTV OF DEATH . �
<br /> Grand Island Ye, � No ❑ Halt
<br /> 9a.RESIOENCE-STATE 9b.COUNTV 9c.QTV,TO WN Ofl LOCATION 8d.STHEET AND NUMBEfl lhdudiny Zip Codel 9e.INSIDE CITV LIMITS �
<br /> Nebraska Hall Cairo 12750 W 1R Rd 68824 ��, ❑ No (�
<br /> lO.MCE-le.q.,WNte,BLack.American Indian. 11.ANCESTPY1�.p.,hefen.M•iacen,G«men,s�al '� 12.�pqqpq�ED �WIDOWED 13.NAME OF SPOUSE l/J wile,give mviden nnnre�
<br /> tal fSpecifyl l��Y)
<br /> White German ❑NEVEfl ❑DIVOHCED Glen A. Ummel
<br /> --_ . __ _
<br /> 14a.USUAI OCCUPATION-lGive kliM o/woik dw�e tluring rms(n�� 14b.KIND OF BUSMESS tNDUSTRV n 1_' 15.EDUCATION SPECFY ONLV HIGHEST CflADE COMv�EIE�I
<br /> /wo.king 17e.even iJ retiiedl �7 �7 Cl/ ��,�,�,a�„y,�,co.i zi co�.a.��.a o,.�;. . ..
<br /> Housewife Domestic 12 �
<br /> � ___ _
<br /> 1 .FATHER�NAME FIRST MIDDLE LAS7 /7.MOTHER FIRST MIODLE MAIDEN SUHNAME � �
<br /> Lou Vierk Emily Silver
<br /> Y_ - __
<br /> 1B.WAS DECEASED EVER IN U.S.AflMED FOqCES7 19a.INFORMAN7�NAME �-�� "�
<br /> �NO a��,I �K'w..�.,,�e��.�..o�..�,�..,
<br /> j Linda Poehler
<br /> _______ ___.
<br /> b.IN� RMANT MAII.ING AODRESS iS7REET OR R.F.D.NO.,CITV Ofl TO WN,SiATE,ZI% .
<br /> P.O. Box 178 Cairo NE. 68824
<br /> -- - ____ _- - __
<br /> 2U.EMBAIMER�SIGNA7UH 8 LICENSE NO. ��� 21a.METHOD OF DISPoSI710N 21h.DA7E 21a CEMETERY OR CREMATOflY-NAf�E
<br /> / �
<br /> �B�„� ❑R��� 02/24/1999 Mt. Pleasant Cemeter�____ __ _
<br /> 22a.F N L HOME-NAME 21A.CEME7EflV Ofl CREMA70RV LOCATION CITV OR iO WN S7A I E
<br /> A fel Funeral Home ❑���a������������ Cairo Nebraska
<br /> ------- -- . ____ __
<br /> ?2�.FUNf_RAI HOME ADDHE^�S (STRffT OR R.F.D.NO.,CITV OR TOWN,STATE.ZIP�
<br /> Wood River, NE. 68883-126
<br /> 23. IMMEDIATE CAUSf (ENTEfl ONLY ONE CAUSE PER IINE FOR lal,(b1,AND Icll � Interval between onsei ane n�nch�
<br /> PANT
<br /> I �
<br /> el �
<br /> DUE TO Ofl AS A CONSEUUENCE OF ----- - --
<br /> I Intnvsl Eetween onse�anA tlea�h
<br /> _'l61 _--_ �
<br /> UUE TO OR AS A CONSEQUENCE OF -----� --� ��
<br /> _.._-
<br /> - `" - _-- -�-� � _ . .._ I ime,�ai nmweP„o��y��.,��d a�:.-,in
<br /> ��� I
<br /> OTHER SIGNIFICANT CONDITIONS-Con6tion wntrbutlnp to�M Meth bm no��Wud PART III IF FEMALE WAS THERE A 26.AUTOPSY 25.WAS CASE REFERRED 10 M[DICnL�
<br /> PART PfiEGNANCY IN THE PAST 3 MONTHS7
<br /> EXAMINER ON CORONEfl?
<br /> 11
<br /> - IAp��10.511 Vp No Ves No Yes No_�__.____
<br /> 2�� 26b.DATE OF INJURV /Ab,qsy,Y..l 28c.HOUR OF INJUflV 28d.DESCRIBE HO W INJURV OCCUflRED- �
<br /> j LJ nccwem ❑U�wa».mmned M
<br /> ' ❑Suiwe ❑Pa�Mi�p 28e.INJURV AT WONK 28L PIACE OF INJURV-A�nome,Ivm,ev«�,fect«v 26g.LOCAiION SiflEE7 ON R.F.D.NO. qTV OFl 70 WN S fA�E
<br /> ottice Ouilding.etc.-/SpeN/y/
<br /> �Hornicida Imr..tqe�ion Vm No❑
<br /> is.DA iE Gf DEATH fMu,Oey,Y./ 2Cta.UA�E�IGNED/Mo,Dey,Y./ "LBD.TIME OF DEATH
<br /> Februar 21 1999 �.�� M
<br /> a`�-� 276.DATE SIGNED/Mo,Dey,Yr./ 27c.TIME OF DEATH �N K y 2Bc.PRpNOUNCED DEAD lMo,Dey,Yr.l 28d.PRONOUNCED OEAD lHouil
<br /> <�
<br /> ��0 2-26-99 11• 09 P M x¢� M
<br /> g� 27d. To the bort ot my knowledge, t tM time,da[ a�tl pace and due to the �� 3 28e. On Me basis of exeminetion aM/a inveatiqacion,in myopinion Oeath occunea at
<br /> causea(sl rtated. //„ [he time,date and place arM Oue m tM causeUl stated.
<br /> (Siqnatme anA Titlel� � � '
<br /> (�q mro end Title) �
<br /> 29.DID TOBACCO USE CON7AI TE TO THE D HP � 30a.HAS OHCAN OH TISSUE DONATION BEEN ONSIDEREDJ 30b.WAS CONSENT GRANTED7
<br /> � YES NO UNKNOWN � YES NO-� ❑ yES NO
<br /> 31.NAME AND ADOHESS OF CERTIFIER IPHVSIC44N,CONONEN'S PHVSICIAN OR COUNTV ATTOMIEVI lType oiRint/ - I �
<br /> William J. Lawton M.D. 2444 W Fai le Av.Gr Is d NE 68803 �
<br /> 32a.REGISTflAN � . 32b.DATE PILEO BY REGISiRAR /Mo,OaY•Yr-1 ����
<br /> . -,
<br /> �IAR 31999 j
<br />
|