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1. DECEDENTS -NAME (Fleet,. Middle, last, Suffix)
<br />Enid Ruth Cederlind
<br />2. SEX
<br />Female ;
<br />6c. UNDER 1 DAY
<br />3. DATE OF DEATN (Mo.,ay,YI.)
<br />May 3, 2013
<br />6. DATE OF BIRTH (Mo.. Vey, Yr.)
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />6. AGE4.ast BMhday
<br />lib. UNDER 1 YEAR
<br />Osmond, Nebraska
<br />(Yra)
<br />65
<br />MOS. :
<br />DAYS
<br />HOURS
<br />.MRS.
<br />February 4, 1948
<br />1. SOCIAL SECURRY NUMBER
<br />506-66 -6884
<br />is PLACE: OF DEATH
<br />mmerrAL ❑ I.p.U«t =Wm ' HaIISILTC ❑ Hospice Facility
<br />Me. FACLRY.NAME (I not institution. glee attest and asINI)
<br />Henderson Care Center
<br />❑ t 0 Dec.denra Horn.
<br />❑ DOA
<br />6c. CRY OR TOWN OF DEATH (InclueN Zip Code)
<br />Henderson 68371
<br />6d COUNTY OF DEATH
<br />York
<br />9.. RESIDENCE-STATE
<br />Nebraska
<br />6b. COUNTY
<br />Hamilton
<br />6t,, CITY OR TOWN
<br />Phillips
<br />6d STREET AND NUMBER
<br />807 W 15 Road
<br />6a APT. N0.
<br />6t, EP CODE
<br />68865
<br />6g. INSIDE CRY LIMITS
<br />❑ Yes ' ril No
<br />10a. MARITAL STATUS AT TINE OF DEATH ail Manfred ❑ New
<br />❑ Mani". but..pwsm ❑ WIdowad ❑ DIeen d 0 Unawea
<br />106. NAME OF SPOUSE (Rot, Middle, Last, Suffix) Nwlh, glee mi den name.
<br />Leon Eugene Cedertind
<br />11. FATHER'S -NAME (First, : Middle, last, &Mix)
<br />John Bernard Henry Borgmann
<br />12 MOTHER'S -NAME (FInt. (addle, Medan E enema)
<br />Julia Adeline Schilling
<br />ee Yes.
<br />13. EVER IN U.& ARMED FORCES? Glee dates of asM If
<br />(Yes, NA, or unit.) No
<br />14.. INFORMANT -NAME
<br />Leon Eugene Cederlind
<br />14b. RELATIONSHIP 7O DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION :;
<br />O .if1 Ij nslim
<br />16a EMBALME R-SIGNATURE '.
<br />Not Embalmed
<br />156. LICENSE NO.
<br />: 16c. DATE(Mo, ay. Yr.)
<br />May 4, 2013
<br />micn"no. ❑Inaaanwe
<br />DR.., D0( .4.yedhi
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN
<br />Grand Island'
<br />WesUawn CtemllWry Nebraska
<br />STATE
<br />17a FUNERAL HOME NAME AND MALINO ADDRESS (Stmt CST or Town,
<br />Livingston- Sondermann Funeral Home, 601 N. Webb
<br />Newman Grove Memorial Funeral Home, 206 N. 3rd
<br />State) :
<br />Road,! Grand Island, Nebraska for?
<br />Street, Box 188, Newman Grove, Nebraska
<br />176. Zip Code
<br />68803
<br />68758
<br />CAUSE OF
<br />DEATH (See instructions and examples)
<br />j
<br />PMT I. Eder E INWa<n.Ma - ieOWAwwlp.rdon.-.r diee.y..owmewo.
<br />erreer. or ve.a.WrINANNen WE amino we awle0r• 00 NOT AEIRENATE
<br />MLMEDIATE CAUSE:
<br />INMEDIArecnusE (Final /1 IA
<br />Morose or eatMtlon resulting a) .
<br />54....4q t„
<br />DO not .NNANAN drarNNW r wear err..(. APPROXIMATE INTERVAL
<br />Enar only one care. on • Ow Add .O.."W 51.0 N n.wee.y. I
<br />Oo deM6
<br />V4-5
<br />r viH
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE OF :. onset to death
<br />Sequentially Zest conditions, If b)
<br />any, leading to the ca se Net.d
<br />on lima DUE TO, OR AS A CONSEQUENCE OF:` onset to death
<br />Enter the UNDERLYING CAUSE e)
<br />(doom or injury that Misted :DUE TO, OR AS A CONSEQUENCE OF: >. onset to death '.
<br />a,. „ nini in demo LAST
<br />d)
<br />PART I. OTHER SIGNIFICANT coNOmONS-Condluom contrIbuthrg to the death but not r.wMna M the underlying .ease glee" In PART L
<br />rP...
<br />*AS MEDICAL CONTJMI E
<br />Ore' no
<br />., IF FEMALE:
<br />Not pregnant within past year
<br />: • Pregnant It ems of death
<br />❑Not pregnant, but preplan amen 42 days of (Ranh
<br />❑ Not pregnant. but pregnant 43 4.y. to 1 yew before death
<br />❑unlewwn if pregnant within the past yew'
<br />�a MANNER OF
<br />❑
<br />❑ Masers ❑
<br />❑ Sulfide ❑
<br />DEATH
<br />IlaNcide
<br />Fading isyssflOsliss
<br />Could not be datemined
<br />21b. IF TRANSPORTATION INJURY
<br />[] DdeeNOperMOr
<br />❑ PIna16IIr
<br />❑ Pedestrian
<br />0 Other (Sp•Nry►
<br />WAS AN AUTOPSY Petroraleor
<br />0 YES CitNO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />: TO COMPLETE CAUSE OF DEATH?
<br />❑YES ID No
<br />22e. DATE OF INJURY (Ma, Day, Yr.)
<br />226.11ME OF INJURY
<br />in
<br />22e. PLACE OF UWRV -At hones, ran, street, factory, dreg building, oorWrU.li.n IA% eto. (S5•CNy)
<br />22d. INJURY AT WORK?
<br />El Yes 13 NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221.1.0CATION OF INJURY - STREET a NUMBER, APT. NO. CITY/TOWN STATE EP CODE
<br />ft
<br />a_
<br />F
<br />. .�
<br />2
<br />IN}. DATE OF DEATH. (Mo. . Yr.)
<br />`
<br />7 �� `�
<br />Z `
<br />p
<br />t ` 1-x
<br />24.. DATE SIGNED (Mo. ay. W .)
<br />246. TIME OF DEATH
<br />m
<br />GATE lRat1ED alt,
<br />51 k
<br />. 71MEOF DEATH
<br />ata6 m
<br />21c. PRONOUNCED DEAD (Mo., Gay Yr.)
<br />244. TIME PRONOUNCED DEAD
<br />m
<br />To the bast of my I.w.Mdg.,
<br />aid aw a the ea.ee(
<br />death occur d at the tlm.. date and paw ' °
<br />(S gi10ws ere TAN
<br />l k,, AID O
<br />24e. On the bash ofsxadnal etand%or 4n0Baetlon. In my opinion dam occurred
<br />ne(.) .fated. (slap iwd Tithe)
<br />M the Ines, dec. and place as due to ties cause(s) . an
<br />DID TOBACCO USE CDNTRInure T
<br />YES Mr ❑ PR!DBABI.t
<br />THE DEATH?. .
<br />❑ UNKNOWN
<br />*r . HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YEE j NO
<br />�p, WASCONSENT GRANTED?
<br />NM Applicable N 264 Is NO ❑ YES - NO
<br />NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />- ) A (h M4 tb,A1 r 4 C* f-Mr..li .✓ 6130
<br />29a REGISTRAR S SIGNATURE 1 .
<br />26b. DATE TILED BY REGISTRAR (Mo.. Day, Yr.)
<br />MAY 16 2013
<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 NE F RASKA ElLVARTAffNT OF EALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY
<br />0
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<br />a
<br />DATE OF ISSUANCE
<br />05/20/2013
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />201504310
<br />STATE OF
<br />NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />d+e-n rI It'ATC :f% r1CATLl
<br />STANLEY'S copPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTI4 N &HEALTH AND
<br />HL k N S'''
<br />27 9
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