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STATE OF NEBRASKA—DEPARTMENT OF HEALTH �O O O O O V V �
<br /> BUREAU OF V1TAl STATISTICS
<br /> � CERTIFICATE OF DEATH
<br /> OECEDENT-NAME FIRST MIDOIE UST SEX DATE Of DEATH(Mo.,Da�,Yr.)
<br /> ,, Geor Iiu o Knuth z. P-lale ,�ecember 13, 1980
<br /> RACE-(�.y.,M�hiM,61ock,Am�rican ORIGIN/DESCENT(�.p.,Italien,Msaican, AGE-lo��einlday UNDER 1 YEAR UNDER 1 DAY DATEOFOIRTH(Mo.,Day,Yr./
<br /> Indian,�k.J(Sp�cily) G�rmon,Nc.)(Sp�cily) � (Yn.) MOS. � DAYS HOURS� MINS. j
<br /> ,. lrhite 3. ���Ze-rican 0 ,,. 63 6b. 6c. 7, OC�'i. 1 1917
<br /> CITI�ANO STATE Of lIRTM(I/no�in U.S.A., CITIZEN OF WHAT COUNTRY MARRIEO,NEVER MARRIED, � I NAME OF SPOUSE(I/v+il�,QIY�TOI(I�ll IIOT�� �
<br /> �am��o�����) WIDOWED,DIVORCED/Sp�ci/r)
<br /> e. H�.11 Count� Ide. q. US:'� ,o. i�;�xried ,,.1�-Iildred Stueven Knuth I
<br /> SOCIAI SECURITY NUM6ER USUAL OCCUPATION(Gir�kind o/rork don�du.ing motl KIND Of 6USINESS OR INDUSTRY COUNTY Of DEATH �
<br /> o/working lif�,w�n iln�i.�d� i
<br /> ,z �"�4-_22-8 16 ,aa. L�,borer �i d� ,sb. Cit oi G. I. ua. Hall !
<br /> CITY,TOWN OR LOCATION Of DEATH INSIDE CITY IIMITS HOSPITAI OR OTHER INSTITUTION-Nam�(1/nof in�ifh�r, li NOS►.Ol IHSi.I�diiob DOA, i
<br /> (Sp�cilyY�i or No1 yir�dnN ond numb�iJ ��pa�i�nl/Eew..��n.,Inpari�n�(SpKilr)
<br /> ub. Gr:�nci Island �k. Yas iad. 211' til. 10th 5t, u..
<br /> RESIDENCE-STATE COUNTY CITY,TOWN OR IOCATION STREET AND NUMSER INSIDE CITY LIMITS i
<br /> (Sp�cif Y��or No) '
<br /> �sa.IJebraskr�. �se. Hall �k. Gr��nd I:�land �sa. 211� �J. 'lOth St. �s.. �`es
<br /> ATHER-NAME IR T MIDDLE UST MOTHER-MAIDEN NAME fIRST MIDDLE U T �
<br /> �e. He A Knuth „ Dor�, Peiper '
<br /> WAS DECEASEO EVER IN U.S.ARMED fORGE57 INFORMANT-NAME-RELAiIONSHIV-MAIIING ADORE55 (SiREEi O��.f.D.NO..CIiY OR TOWN,SiATE,Zlry.
<br /> �r...�o.o,,,,,�) u�r...9�...o,o�e do�..oi..���.)
<br /> ,e. iJo �v. I�1xs. I<Zildrod ' uth=�7iie-2 1 Ut Gr•G.nd Is tand Pde�
<br /> BURIAL,Cremation,Removal DAT CEMETERY OR CREhUTORY-NAME IOCATION CITY OR TOWN STATE
<br /> �. Bur'a zob. 12 16 80 ��i•est '�t• I�It; -r'��l sod. :L' � � � I�T
<br /> FM6A SIGN�LI(RE 6 LICENSE NO. �ZU FUNERAI MOME-NAME AND ADDRE�S (STREET OR R.F.D.NO.,C�it O�10WN,S1ATE,21ry
<br /> ,,. , zz. Liv' ��s�ori—aond r 's 0` 1• iioeni Grr.�nd Island Tde�
<br /> ATE OF DEAj (Mo.,Doy,Yr.) DATE SIGNED(Mo.Doy,Yr.) HOUR OF DEATM
<br /> p Z,�„
<br /> � 12''i�{�VD ��Z
<br /> u 27a. � � 24a. 44b. /p
<br /> �� OATE SIGNED(Mo.,Ooy,Yr.) MOUR OF DEATH a=�T PRONOUNCEDOEAO PRONOUNCEDDEAD(Hour)
<br /> n=_
<br /> p E� (Mo.,Doy,Yr.)
<br /> �� 2�b. 12�16�C7� 23e. 12 Z 50 p• M u�Z� 24c. 4 .
<br /> �
<br /> E£ io�M bn�el iny Yno.l�dp�,dwtA xcun�d o��h�ti�.doN and ac�and du�to M� �p O On M�bau�ol�aaininatlon and/or Inv���ipa�ion,in my opinfon d�oth xcun�d a�
<br /> y cow�(Q�MNd., / � F°,�v �6�ti�.da��ond plx�and du�ro rh�cauwld Uo��d.
<br /> �-t �/ �o
<br /> 23d.fs�o�e�u.:arnd ifH�)� � /'v� � 14a.lSipnolur�and TiN�I�
<br /> NAME ANO ADDRE55 Of CERTIFIE (PHYSICIAN,CORONER'S PMYSICIAN COUNTV ATTORNEY)(Type or Prinl)
<br /> z9 Richaxd F. Del•Iay, T�I. D., 721 �J. 7th St., G-r���d Is:.and, i+e. 6�3�:U1
<br /> REGISTRAR � -� DATEiRf�EIVED BY REGISTRAR(Mo.,Day,Yr.)
<br /> 46a./Sipnoron//'��� l../ (��;��?r�./ ��"t%"Z.<<� IL.�'t�/��/�L L"C'?,� � �/�U
<br /> 27. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE VER LINE fOR/a),(b),AND(c)) i Int�rvol l�n+��n on���aed d�oM
<br /> i
<br /> PART
<br /> ;,, Yentricular asystole � Immedi@ate
<br /> DUE TO,OR AS A CONSEQUENCE Of: , lo��nol b�n+�•n on•��and dwM
<br /> ,b, Aeute myocardial infarction (11-23-80� re—infaret 12-13-80) ; See to left
<br /> DUE TO,OR AS A CONSEOUENCE Of: � Int�.vol b��w.•n om�t ond d�a�A
<br /> ��� �
<br /> PART OTMER SIGNIfICANT CONDITIONS-Condi�ion�<onhibu�inp ro dwth bu�no�.•land ►ART 111.If FEMAIE,wA5 TMERE A AUT0t51' wAS CASE�EFE�RED TO MEOICAI
<br /> ViEGNANCY M TNE PASi�MONTMSi (Sp�ail�Y��or No/ EXAMINER OR CORONER
<br /> �� (Sp�cilr Y�t or Nol
<br /> Hypertension r��❑ N,❑ z8. No z9 No
<br /> ACCIDENT,SUICIOE,MOMICIDE,UHDEt., DATE Of INIURY(Mo.,Dar,Yr.) MOUR Of IPUUNY DESCRIlE MOW INIURY OCCU�RED
<br /> OR►ENDING INVESTIGATIOH.�Sp�ailrl
<br /> JOa. 706. 90c. M 30d.
<br /> INIURY AT WORK MACE Of�N1URY-A1 how�,larni,Nrwt.(oclory, LOCATION STlEET OR�.F.D.No. CIiY OR TOWN STATE
<br /> (Sp�ci/r Y��w No) offic�buildiny,Nc.fSp�<il�l .
<br /> �o.. oof. . auy
<br /> �� �� , �
<br /> ��, ����
<br /> � �.�� �
<br /> �-..��-"AHEN� �$,�'�'-' �OPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br /> �_J $Tb1'�►`��DEPKARTMENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br /> � .. A TRUE GO:P�=� OE AN ORIGINAL RECORD ON FILE WITH THE STATE
<br /> �� �DEPARTME�i'�.rOF HEALTH, BUREAU OF VITAL STATISTZCS , WHICH
<br /> � ..����.,�,Fr ,�a"'�,,(�►L- DEPOSZTORY FOR VITAL RECORDS .
<br /> � •.��, ��.� ,,�..,. . °�. ,
<br /> � �
<br /> ��.�Y��; J�,, . . ��/��_ ��I
<br /> DIRECTOR OF VITAL STATISTICS AND ASSISTANT STATE REGISTRAR
<br /> LINCOLN, NEBRASKA,_ Issued December 24, 1980
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