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1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Walter Harold Luers
<br />2. SEX. ' ,
<br />Male
<br />S, DATE OF DEATH (Mo.,Day,Yr.)
<br />Aphl 21, 2015
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />94
<br />Sb. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />6. DATE OF BIRTH (No., Day, Yr.)
<br />March 26, 1921
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL mostly NUMBER
<br />508 - 8483
<br />ea. PLACE OF DEATH
<br />HOSPITAL: ❑ IaPeth at 24iE6: ® Nursing Home/LTC ❑ Hospice Facility
<br />❑ ER/Outpatlent ❑ Decedent's Home
<br />❑ DOA 0 Ddror($P1c Y)
<br />8b. FACILITY -NAME (if not Institution, ohm street and number)
<br />Tiffany Square Care Center
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Cod.)
<br />Grand Island 68803
<br />ed. COUNTY OF DEATH
<br />Hall
<br />ea. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />90. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />3119 West Faidley Avenue
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />0 Yea ❑ No
<br />10.. MARITAL STATUS AT TIME OF DEATH i;i Warded ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />106. NAME Oln SPOUSE (First, Middle, Last, Suffix) n wffe, give maiden name.
<br />Prue Rebecca Boyles
<br />11. FATHER'S -NAME (Fiat, Middle, Lest, Suffix)
<br />Walter Henry Luers
<br />12. MOTHER'S •NAME (First, Middle, Malden Surname
<br />Clara Elsie Siebert
<br />13. EVER IN U.S. ARMED FORCES? Give dabs of service N Yea.
<br />(Yea, No, or unk.) Yes dates unkacem
<br />14a. INFORMANT -NAME
<br />Prue Rebecca Luers
<br />141). RELATIONSHIP TO DECEDENT
<br />Wife
<br />15.111E71100 OF DISPOSITION
<br />❑ B`ai'l ❑bw'•d°
<br />MCmnNAn ❑Erdo.t..nt
<br />❑ NemovN ❑OIMn(tipeclryl
<br />lea. EMBALMER- SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />April 22, 2015
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />178. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Term, State)
<br />All Faiths Funeral Horne, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />1a. PART 1. Enter II* PitiLLOtteRigg - dtearow . 84u4.,, or eempllo0o.w. that dkady e,nre.d the Mira. od NOT We Amino) .voids such as =Ow an.d, APPROXXNNATE INTERVAL
<br />,aecketory .n 06, or v...tricubr tAew.Pa„ w1P,oat.Matnp the 10 00 NOT AE0RI MATE. Ewer only ear eau.a an a are. Add MdNionM Ilnos I noossoo y.
<br />IMMEDIATE CAUSE: M�+ onset to death
<br />CAUSE (F(Final J r ° t
<br />Missies or condition resulting a) 1 /x / d €4
<br />disease v � ` "'
<br />in death) ����
<br />DUE TO, OR AS A CONSEQUENCE OF: onset 10 death
<br />Sequentially Ilst eordidoM, If
<br />any, loading to the cause listed b)
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE o)
<br />(disease or Injury that initiated
<br />the events muffing In death) DUE TO, OR AEA CONSEQUENCE OF: onset to death
<br />LAST
<br />6)
<br />19. PART N. OTHER SIGNIFICANT CONDITfONS-CcndNbns contributing to the death but not resulting in the underlying cause given M PART I.
<br />19. WAS MEDICAL. EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES OY^t`+
<br />20. IF FEMALE:
<br />❑Not pregnant within past year
<br />❑Pregnant at time of death
<br />❑Not pregnant, but pregnant within 42 days of death
<br />❑Not pregnant, but pregnant 43 days to 1 year before death
<br />❑Unknown N pregnant within the past year
<br />21a. AMMER OF DEATH
<br />Natural ❑ Homicide
<br />❑ ACCdent ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />2 1 . 1 1' TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Pmeenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY FORMED?
<br />❑ YES
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE C Of DEATH?
<br />❑ yes
<br />22a. DATE OF INJURY (M.., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At 1101M, faun, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT
<br />❑ YES / NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />2Zr. LOCATION OF INJURY - STREET S NUMBER, APT. N0. CITY/TOWN STATE ZIP CODE
<br />X 11.
<br />i t T
<br />u
<br />o <
<br />g CH
<br />1 1
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 21, 2015
<br />� yyy UUg
<br />'
<br />`g
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />23b. D • • (Mo.. Day, Yr.)
<br />a 21, 2015
<br />23c. TUNE OF DEATH
<br />5:45 am
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED 05*0
<br />rn
<br />23d .' of my ... death occurred ate tine, dab and pipe U
<br />. j tir
<br />a -a:jur • . CSUSe . . ( Mtiero Title) o CZ
<br />r
<br />0, o ti
<br />2.4e. On the basis of examination and/or Investigation, In my opinion death occurred
<br />*the tine, data and Dlese and due to the censorial) staled. (Signature and. Tits)
<br />25. DID TOBACCO CONTRIBUTE TO THE DEATH?
<br />❑ YES ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE TON BEEN CONSIDERED?
<br />0 YES -
<br />266. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO ❑ YES NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />L
<br />John A Wagoner M.D. 800.: Aloha Street Crega Tetlwnd NA 6W';
<br />26a. REGISTRAR'S SIGNATURE f /
<br />4 • U
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />APR 2 7 2015
<br />W
<br />LL
<br />W
<br />U
<br />O
<br />DATE OF ISSUANCE
<br />04/29/2015
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN `SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIT4C'47ECOIDS a.
<br />201503559
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES-
<br />STANLEY
<br />ERVICE
<br />STANLEY S COOPER
<br />ASSISTANT STATE REGISTRAR =',
<br />DEPARTMENT OF HEALTH AAA
<br />HUMAN SERVICES
<br />
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