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4i.
<br />WHEN TMS COPY CARRIES TIE RAISED SEAL OF THE NEBRASKA HEAL- nIAMMIi
<br />SYSTEX IT CERTIFES TFE BELOW TO BE A TRUE COPY OF THE D CBI
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, WTA_
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE 200100089
<br />-:
<br />MAY 2 11999 ASSISrMTSTA
<br />LINCOLN, NEBRASKA HEALgIy@_
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND M_ A
<br />vTTAL STATISTICS=
<br />CERTIFICATF, OF
<br />SERVICES
<br />FILE WITH
<br />WHICH IS
<br />i AND SUPPORT
<br />O
<br />N
<br />O
<br />O
<br />O
<br />O
<br />Cove.
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day Yearl
<br />M
<br />Male I
<br />D
<br />I . CITY AND STATE OF BIRTH pl no,it U.SA.. name country/
<br />O
<br />. UNDER 1 DAY
<br />6. DATE OF BIRTH ( Month. Day. Year)
<br />5c. HOURS MINS.
<br />Campbell, Nebraska
<br />(Yrs.) I 5b. MOS. DAYS
<br />73
<br />1 January 20,1926
<br />7. SOCIAL SECURTIY NUMBER
<br />Be, PLACE OF DEATH
<br />506 -20 -1300
<br />ct
<br />c D
<br />Bb. FACILITY - Name /l, not msb/dion, give sheet and number/
<br />1015 West 5th Street
<br />i�
<br />► �,
<br />8d. INSIDE CITY LIMBS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />..-1`�
<br />C_
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATIOIJ
<br />9d. STREET AND NUMBER /Including Zip Code/
<br />r_
<br />Nebraska
<br />Hall
<br />Grand I 1 nd
<br />m
<br />CI)
<br />Yes ® - El
<br />O
<br />° -n
<br />I�
<br />12. ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE IN 1wb. give maiden name/
<br />ek.) lSpacifyl
<br />White
<br />(Specify/
<br />American
<br />NEVER DIVORCED
<br />M
<br />1 Elaine Bartels
<br />14a. USUAL OCCUPATION /Give kind ot work done dung most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />d working lib, even drehredl
<br />Forklift O rator
<br />�h
<br />16. FATHER - NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Leslie
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />_
<br />19a. INFORMANT -NAME
<br />d
<br />rn
<br />rD
<br />Elaine Bierhaus
<br />19b INFORMANT MAILING ADDRESS (STREET OR R.F D. NO , CITY OR TOWN. STATE. ZIP)
<br />1015 Wes 5th Street, C and island mah-rAQirA Appm
<br />20. ER - SIG T E 8 UC NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY . NAME
<br />Q
<br />o
<br />05/15/1999 Westlawn
<br />Memorial Park
<br />2a. FUNERAL HOM - NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />pfel- Butler - Geddes Funeral HOM
<br />❑ CfBinabon ❑ D0ndtion
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO. CITY OR TOWN. STATE, ZIP)
<br />1123 West Second Street, Grand Island, Nebraska, 68801 -5899
<br />23. IMMEDIATE CAUS (ENTER ONLY ONE CAUSE PER LINE FOR fa). Of, AND (c)) Interval between onset antl death
<br />PART a_ � I � /� p,�
<br />l�le,jl C�..iC�`
<br />(al s,a Y -L d-I'J 1
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />t
<br />rot I
<br />DUE TO, OR AS A CONSEQVENCE OF: Interval between onset and death
<br />- I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to mit death but rot related PART
<br />PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO CAL
<br />O
<br />Co
<br />N
<br />EXAMINER OR CORONER.
<br />(Ages
<br />10 -541 Yes No
<br />Yes No
<br />Yes No
<br />26a.
<br />4i.
<br />WHEN TMS COPY CARRIES TIE RAISED SEAL OF THE NEBRASKA HEAL- nIAMMIi
<br />SYSTEX IT CERTIFES TFE BELOW TO BE A TRUE COPY OF THE D CBI
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, WTA_
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE 200100089
<br />-:
<br />MAY 2 11999 ASSISrMTSTA
<br />LINCOLN, NEBRASKA HEALgIy@_
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND M_ A
<br />vTTAL STATISTICS=
<br />CERTIFICATF, OF
<br />SERVICES
<br />FILE WITH
<br />WHICH IS
<br />i AND SUPPORT
<br />O
<br />N
<br />O
<br />O
<br />O
<br />O
<br />Cove.
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day Yearl
<br />Donald Edward Bierhaus
<br />Male I
<br />May 11, 1999
<br />I . CITY AND STATE OF BIRTH pl no,it U.SA.. name country/
<br />5a. AGE - Last Birthday I UNDER 1 YEAR
<br />. UNDER 1 DAY
<br />6. DATE OF BIRTH ( Month. Day. Year)
<br />5c. HOURS MINS.
<br />Campbell, Nebraska
<br />(Yrs.) I 5b. MOS. DAYS
<br />73
<br />1 January 20,1926
<br />7. SOCIAL SECURTIY NUMBER
<br />Be, PLACE OF DEATH
<br />506 -20 -1300
<br />HOSPITAL: Inpatlert OTHER: ❑ Nursing Home
<br />❑ ER Outpatient ® Residence
<br />Bb. FACILITY - Name /l, not msb/dion, give sheet and number/
<br />1015 West 5th Street
<br />❑ DOA ❑ Other /ten"'
<br />fic. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMBS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yes Ni No ❑
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATIOIJ
<br />9d. STREET AND NUMBER /Including Zip Code/
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand I 1 nd
<br />Yes ® - El
<br />10. RACE - (e.g.. White. Back. American Indian.
<br />11. ANCESTRY le.g.. Italian. Mexican, German, ek)
<br />12. ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE IN 1wb. give maiden name/
<br />ek.) lSpacifyl
<br />White
<br />(Specify/
<br />American
<br />NEVER DIVORCED
<br />M
<br />1 Elaine Bartels
<br />14a. USUAL OCCUPATION /Give kind ot work done dung most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />d working lib, even drehredl
<br />Forklift O rator
<br />Elementary or Secondary 10.121 Cc" 1 t .4 a 5• i
<br />16. FATHER - NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Leslie
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />_
<br />19a. INFORMANT -NAME
<br />Ives. no. cr unk.) 1 It yes. give war and datee d servi-esl 7/24/1944
<br />'Yes World War II 2
<br />Elaine Bierhaus
<br />19b INFORMANT MAILING ADDRESS (STREET OR R.F D. NO , CITY OR TOWN. STATE. ZIP)
<br />1015 Wes 5th Street, C and island mah-rAQirA Appm
<br />20. ER - SIG T E 8 UC NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY . NAME
<br />�•►-, '46_ 1071
<br />® Burial ❑ Removal
<br />05/15/1999 Westlawn
<br />Memorial Park
<br />2a. FUNERAL HOM - NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />pfel- Butler - Geddes Funeral HOM
<br />❑ CfBinabon ❑ D0ndtion
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO. CITY OR TOWN. STATE, ZIP)
<br />1123 West Second Street, Grand Island, Nebraska, 68801 -5899
<br />23. IMMEDIATE CAUS (ENTER ONLY ONE CAUSE PER LINE FOR fa). Of, AND (c)) Interval between onset antl death
<br />PART a_ � I � /� p,�
<br />l�le,jl C�..iC�`
<br />(al s,a Y -L d-I'J 1
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />t
<br />rot I
<br />DUE TO, OR AS A CONSEQVENCE OF: Interval between onset and death
<br />- I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to mit death but rot related PART
<br />PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO CAL
<br />PREGNANCY
<br />II
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER.
<br />(Ages
<br />10 -541 Yes No
<br />Yes No
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY /MO.. Day. Yc/
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />AccWenl � Untleterm,ned
<br />M
<br />Suicide n Pending
<br />26e. INJURY AT WORK
<br />26f. odi e E O�i�JURY /At _ , farm, street. factory
<br />hom8
<br />06i bu SCecnryl
<br />26g. LOCATION STREET OH R.F.D. NO. CITY OR TOWN STATE
<br />❑ Homicide Investigation
<br />Yes ❑ No
<br />27a. DATE OF DEATH /MO.. Day. Yr.)
<br />28a. DATE SIGNED (MO.. Day Yr.)
<br />28b TIME OF DEATH
<br />May 11, 1999
<br />E
<br />S
<br />I
<br />M
<br />27b. DATE SIGNED (MO. Day. Yrl
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD /Mo.. Day, Yr.)
<br />28d. PRONOUNCED DEAD (Hour)
<br />May 14, 1999
<br />7:40 a.
<br />ii
<br />M_
<br />M
<br />27tl. To Vw best d my knowledge. de curred� me, date antl place and due to tte
<br />28e. On the basis d examination and,or investigation, in my opinion death occurred at
<br />cause(sl sated. n
<br />/o
<br />6
<br />the time, date and place and due a the causes) sated.
<br />ISignature and Title 10 -•a_''"/"�
<br />nature and Tide
<br />29. DID TOBACCO USE CONTRIBUTE TO THE D TH? 30.a
<br />HAS ORGAN TISSUE DONATION EN SIDERED? 30.0
<br />WAS CONSENT GRANTED?
<br />❑ YES ❑ NO NKNOWN
<br />❑ YES NO
<br />YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PH SICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI (Type or prmll
<br />Dr. Daniel R. Cronk, 908 N. Howard Ave. Grand Island, Nebraska 6ARoa
<br />I 320. RiaBTRAR A z 32b. DATE FLED BY REGISTRAR /Ma, Day. Yr.)
<br />
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