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T = D � � `� �� " .. -- 'b� !1 Cl Z l") _ � rn a -a � 3 = D 7C rn � Cv --1 m p ,-r . �4 m � v � � o � 6� � _ ' �`"°� � � � � e. ,S� � � = rn � H ^'� ' m � r-�''- � � _ Q r� 3 r D Q � S W � S� f� � � CA � N �� n � U,j W ....L � � rn ct, Ca �, u? � � #� � i G �:�. �� �N�EN 7iA�0l�'�C�fli�'��FA/9ED SEAL OF THF� '", . SYSTEII�IT CERT�3 THE BELOW TO BE A TRl/E COF�Y OF THE OI+�O/NAL RECOA[i__ _ _Ntl�fi =; THE NEBRASKA HEALTH AND HUMAN SERVICES SY8TEM.VITAL 3TAT/STICS SEC}Yifl1��_;. THE LEQAL DEPOSITORY FOR VITAL f�ECORD3. � 3;-_ _ .�:��",_'� � r - DATE OF ISSUANCE _ _ - ANf��€�: _ J A N 2 4 2000 2 0 0 0 0 0 9 8 9 assisranrr s€,a��orst�;�" - LINCOLN,NEBRASKA HEALTH AND HUMAN SE�3VIC�S.�'XS�! _r - STATE OF NEBRASKA-DEPARTMENT�F F�.ALTH'4ND[-1�M�N S��CES FII3�NC6:�;N�;�RT VCTA[.STATLS11CS ' ---_ ' CERTIFICATE OF DEATH ^ V'==-_==_�� 1.DECEDENT�NAME FIRST MIDDLE LAS7 2 SE% 3.DATE OF DEATH /Monfn Day.Yearl Delbert Lawrence Martens Male Dec. 9 1999 �.CITV AND STATE OF BIRTH /Ilnd'n U 5 A..name eounhY/ Sa.AGE-LaSt Birthtlay UNDER 1 VEAR UNDER 1 DAV 6.DATE OF BIRTH IMonfh.Day Year/ �Vrs.l Sb.MOS. DA�S St.HOUAS M W S D e c. 16 19 2 6 Belvue, Kansas �� 8a PLACEOFDEATH 7.SOCIAL SECURTIV NUMBER ❑ HOSPITAL X ��Datient OTHER�. Nursing Home . 514 14 2231 � EROutpauem � ResWe�ce !b.FACILITY-Name lll no��n�fifufan.9�ve sheel��0 nur^beil � DOA � 01her ISOeah'i Immanuel Medical Center �,INSIDECIfi'l�M1TS 8a CWNTVOPDEATH k.C .TpWN OR LOCATqN OF DEATH . . _ ;,Y� ,,o Doug�as , Omaha � � 9e INSIDE pTV LIMITS 9a.RESIDENCE-STATE 9b.COUNTY . 9c.pTY.TOWN OR LOCATION 9tl.STREET AND NUMBER /InclutlirrgZiOCodel VB9� No❑ Nebraska Hall Grand Island 2724 �-1. Cotta �0 AACE-le.g.,W��e.Biack.American Indiart �1.ANCESTav le.g-Italien.Me■ican,German,e�cl 12.�MAFRIED ❑H'IDOWED 13 NAME OF SPOUSE !ll wAe.g��e maiden namel _ �soe��N� w-vta - ��4� �,Baitvr ToA1Btt •<• •>• . etc I UN -- �t`.�� ,@,.- ,..s r� . .��!.-�� .�i.:.. .�� .��'•t� .�6�1��:._ " .. . . . . 15:EDUCATION ISPMnN onN nqn�at a0�cunWMed) ..N� ALOCCUPATION �ICii�+tiMMwcrkdwN ^r°p � tb. � Cdl ei�.ao�5•i ENmenuryorSeconEary IO�t21 � a'"°"`"'9"�'''�«"r.M�°°i P 1 umb in 8 Plumber FIRS1 MIDOLE MAIDENSURNAME FIRST MIDDIE UST 17 MOTMER � 16.FATMER-NAME � Emil Martens __ Martha Herron le.WAS DECEASED EVER IN U.S.ARMED FORCES? �9a.INFORMANT-NAME �Vp,no.or unk.� Ilf yes.grve war and dates ol servicea� E 1 e ano r TZS Y t e?1 S _ - i no - -- i 19b.INFORMANT MAiUNG ADDRESS ISTREET OR R.F.D NO..CITY JR TOJJN.STATE.21P1 2724 West Coll S Nebraska 68803 --- 20.EMBA ER�SIGNATURE 8.ICENSE NO. � 2ta.METh000FDi5POSiTiC�, 27b.�AT 21a CEMETERVORCREMA70��+ NAME Cemetery a� „s� �8�,,,� �Remc+ai � Pec. 13. 1999 Westlawn Memorial Park 2 2 ERAL HOME�NAME 21tl.CEMETEFV OR CREMATORV LOCATpN CITv OR TOWN STATE ❑�ro�.n«+ ❑o�^�� Grand Island, Nebraska _ Kleine Funeral Home - Inp.FUNERAL HOME ADDRESS (STREET Oi1 R.F.D.NO_Ci7Y Oii TO�MN.$TATE.2IPI - 3213 W. North Front St. ,_ Jrand Island, Nebraska 68803 i Inte�vaiCeNreenonseta�tloeav �, IMMEDIATE CAUSE IENTER ONLV ONE CAUSE PEA LINe FOR ial.Ibl.AND(cll / � PART � C,� /� M `A�! /O �"l� U �' 1 �C C/l.. /C.� /'Y+ I G: � lal � � � i Imervai between onset anE tleain DUE TO,OR AS A CONSEOUENCE OF � • � • i (b� ___ .___ ._ . _ ' Inib�va�Uen.x�.,onae�e,�d d,•sv� D �� PART III IF FEMALE.WAS�HERE A 2A AUTOPSV I 25.W AS CASE REFERRED TO MEDICAL .�OTHER SIGNIFICANT CONDITIONS-COn�Nlion�CmtribA�p��M�� pqEGNANCY IN THE PAST�MONTHS? EXAMINER OR CORONER� � . . � . . � , . . . . �(�10-541 Ves No Vee No Mw No 26a 26b DATE OF INJUFl� lMo..Oay.Yc/ 26c.HOUR OF INJURY 26d DESCRIBE HON1�NJURV OCCURRED � AcoEent � Undtl�ermme0 M . � $mci0e � Pe�tl�^9 26e.�NJURV AT WORK 26f.PLACEOb.INJURV-�1t home.�arm.straeL IacMry 269.LOCATION STREET OR R.F.D.NO. G7V OR TOWN STATE oM�ce bu� ug.e�c. lSpecAyl . � lipmit�tle InvesUgaUon Ves❑ No� 28a.DATE SiGNED IMo..Day.r�J 28C TiME OF DEATH 27a.DATE OF DEATH /Ma..Day.Yi.l . , December 9, 1999 agg5�' M ' E� Y�Y gg� PRONOUNCED DEAD /Mo_Day.Yrl 28d.PRONOUNCED DEAD (Hourl ._. `,�6 27b.DATE SIGNED /Mo.Day Yrl 27e:�TIME Of DEATH y `n Z� M �, � December 17 9 5:49 M g�� , 2Be.On the basrs ot azaminaGon aM�or.inveslgation,In my op�nwn Ceaih.occurre0 al �� 27tl �o the best ol my kn ge. cur at M+e�U�tlate dacB aM a�ro Me `-o s �� -�the ume.Eate and Dlace and tlue lo tlie cause151 sta�ed. ~" "l causelsl stated. � �/l � �/ �7 Si naWre and Title IS and 7itle ► � ' M.DID TOBACCO USE C ON 7 R I B U T E T O T H E D E A T M? 30.a HAS ORGAN OR TISSUE DONATION BEEN CO SIDERED'+ 30.b WAS CONSENT GRANTED° ` � VES �O � UNKNOWN � VES NO 'O �ES �N� 31 NAME AND ADOAESS OP CEATIFIER IPHVSICIAN,COAONERB PHVSICIAN OA COUNTV ATTORNEYI 17ype a Prinll Abraham P. Mathews, . 6901 No. 72 St. ��2244 Omaha, NE 68122-1799 32b.DATE FIlEO BV REGISTRAR (Mo..OsY Yc) � 32�.REGISTRAR � 1999 J '