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1. DECEDENTS-NAME (First, Middle, Last, Suffix)
<br />Ted Lechner
<br />- 2. SEX ' ` - ..-
<br />Male
<br />- 8. DATE OFDEATTI MO„Cay;YR1 - -
<br />June 19, 2014
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE -Last Birthday
<br />(Ye.)
<br />89
<br />Sb. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, TO
<br />November 14, 1924
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINE.
<br />7. SOCIAL SECURITY NUMBER
<br />508 -12 -7648
<br />Ea. PLACE OF DEATH
<br />HOSE1laL ❑ Inpatient QIHS&D Nursing Home/LTC ❑ Hoaplce Facility
<br />❑ ER/Outpatient ® Meade*** Home
<br />1:1 DOA ❑Othe (Sp•ciy)
<br />Bb. FACILITY-NAME (I not Institution, give street and number)
<br />4311 West 13th
<br />8c. CITY OR TOWN OF DEATH (Inciuds Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE I
<br />Nebraska
<br />lib. COUNTY I
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2d. STREET AND NUMBER
<br />4311 West 13th
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® Yea ❑ No
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married 105. NAME OF SPOUSE (First, Middle, Last, Suffix) HMIs, give maiden name.
<br />❑ Raffled, but separated RI Widowed ❑ Divorced ❑ Unknown Imogene Louise Neumann
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />William Joseph Lechner
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Augusta Hershey
<br />13. EVER IN U.S. ARMED FORCES? Give dabs of Service if Yes.
<br />(Tel, No, or Unk) Y0s 7/17/1943 - 1/4/1946
<br />14a. INFORMANT -NAME
<br />Roger Paul Lechner
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />15. METHOD OF DISPOSITION
<br />Mandel ❑bawon
<br />❑Cremation ❑Emomtaeam
<br />DR.... ❑ IatndM
<br />16a. EMBAL R-SIG N IRE
<br />JC �Q�
<br />16b. LICENSE NO.
<br />f/J
<br />1 ' [5�
<br />16c. DATE (Mo., Day, Yr.)
<br />June 23, 2014
<br />16d. CEMETERY, CREMATO OTHER LOCATION CITY/TOWN STATE
<br />Westlawn Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Stab)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />14. PART L gnaw the fdal9SLe9 aril - disease., kdwws. or cc,osik dononth that dkMy “used me death. DO NOT aver congeal rams such a wen N 1. APPROXIMATE INTERVAL
<br />sepketory ant, or ventriculandealbn without Mowing the etiology. DO NOT ABBREVIATE. Enter n o Sawn on • lino. Add addebas M ea
<br />How n•awy b
<br />er only or e tkA-4 r •sr'y
<br />IMMED AUSE: I' onset �� deaM ,1
<br />in IMMEDIATE CAUSE (w (Final s `-��t olot ea or condition reseltlng a) t
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />SequMgally list condlttone, M
<br />any, ladling to the cause listed b)
<br />on linen DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that initiated
<br />the Seems reeetang in Math) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST
<br />d)
<br />18. PART IL OTHER SIGNIFICANT CONDITIONS - Condition contributing to the Meath but not muffing In the underlying muse given In PART L
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES O
<br />`/
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of dean
<br />❑ Not pregnant, but pregnant within 42 dap of death
<br />❑Not pregnant, but pregnant 43 days to 1 year before death
<br />❑Unknown If pregnant within the past year
<br />21a. NER OF DEATH
<br />atunl ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide Could not be debmlinetl
<br />❑
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Sp•cie)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES l
<br />21d. WERE AUTOPSY FINDINGS SE AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES l
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY•At home, farm, street, factory, offke building, construction site, eta. (Specify)
<br />22d. INJURY AT W��K?
<br />❑ YES {O NO
<br />22s. DESCRIBE HOW INJURY OCCURRED
<br />22E. LOCATION OF INJURY. STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />W Y
<br />o C
<br />23a. DATE OF 0 RI (Ms., Yr.)
<br />0
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />Sib. TIME OF DEATH
<br />22b. DATE SIGNED (Mo Day, Yr.) - /
<br />230. TIME OF DEATH ,/
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />O
<br />o the but of my knowledge, death occurred at the time, date and place g g
<br />Mad due to the stated. (Signature and Title)
<br />V
<br />2M. On the bole of examination and/or Investgatlon. In my opinion death occurred
<br />at the time, dab and place and due to the causes) stall. (Signature and MUM
<br />w
<br />25. DID � - 0 CONTRIBUTE TO THE DEATH?
<br />❑ / S ❑ PROBABLY ❑ UNKNOWN
<br />Zee. HAS ORGAN OR Tissue
<br />n BEEN CONSIDERED?
<br />I 0 YES , • !
<br />28b. WAS CONSENT GRANTED? 1
<br />Not Applicable R 26a k NO ❑ YES (J N
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />••• : -••t a -1 :AO L• -_. • -i Grand Island NE 68803
<br />26a. REGISTRAR'S SIGNATURE
<br />4r ' / ,d f l f
<br />Mb. DATE FILED BY REGISTRAR (Mo., Day, Yr,)
<br />JUN 2 4 2014 1
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALT -AND IMAM F`SF VICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA*A, DEPARTMENT O 'HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VLTAL R.ECORDS..
<br />DATE OF ISSUANCE
<br />01/27/2015
<br />LINCOLN, NEBRASKA
<br />:
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN BERVICEt
<br />STANLEY S. COOPER
<br />`ASSISIAI ST,>111 REGISTRAR
<br />:I E AR9 M TTOW i15t44LT t-1, AND
<br />`HUMAN SERVICES
<br />•24368
<br />
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