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<br />WHEN THIS COPYCARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE "M-7, THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION,
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS -
<br />DATE OF ISSUANCE
<br />200100616
<br />OCT 2 3 2000 ASSISTANTSTATEmmisTiMA
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE XND-$VPPORT'
<br />VITAL STATISTICS --
<br />CERTIFICATE OF DEATH _
<br />'DECFDENT -NAME _.. __.- _._. —___ _
<br />FIRST MIDDLE LAS' T $EX 3. OATE OF DEATH Moom D.ar
<br />Carl NMN Harders Male _ October 11, 2000
<br />4 CITY AND STATE OF BIRTH ;/ /norm Uy�A. �anre c nrry 5a AGE - Last Birthday UNDER I YEAR UNDER 1 DAY 6 DATE OF BIRTH Mgnlh. Day 1"earl
<br />Wood River, Nebraska Vrs l(�2 b MOS DAYS 15c HOURS MINS Tune 8, 1908
<br />7 SOCIAL SECURTIV NUMBER � — " --
<br />Ba PLACE OF DEATN ---- -- ----- - - - - --
<br />506 -46 -0015 [X]
<br />HOSPITAL Ho,,
<br />b10alienl OTHER ❑ Nwsmq
<br />8b FACILITY Name //I IV, - 1r;fur;on. q 1 srreel t dnumb¢ /I ❑ ER Outpatient' ❑ Residence
<br />St. Francis Med Center ❑ ,DOA ❑ Other spe,fvl — ___ - --
<br />6c CITY TOWN OR LOCATION OF DEATH ed INSIDE CITY LIMITS 8e COUNTY OF DEATH - -- -- - --
<br />Grand Island Bl al
<br />Yes � No ❑
<br />9a RESIDENCE - STAIE ' 9b COUNTY 9e CITY. TOWN OR LOCATION 90 STREET AND NUMBER ;rnoudrng6;q� V 191 INSIDE CITY LIMITS
<br />Nebraska i Hall Grand Island 1405 HWY 34 G.I:
<br />Yes ' No ❑
<br />10 RACE (e.g., White Black Amencan Indian 11 ANCESTRY Ieq Italian, Mexican, German. etc) 12 MARRIED WIDOWED 13 NAME OF SPOUSE ;nw fe
<br />eK I ISoec .grve ma;den namel
<br />ISoe� Nl
<br />lte German NEVER DIVORCED
<br />MARRIED Alvira Krce er (de'" I___
<br />Ida USUALOCCUPATION /G;vekrnd0/workdonedunngmosr 141 KIND OF BUSINESS INDUSTRY 15 EDUCATION S eci
<br />o/workrng nle. even d reeredr p N only highest grade completetl)
<br />Elememary or Secondary r0 121 College i 1 -v o S
<br />16 FATHER -NAME FIRST MIDDLE LAST n MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Martin Harders Margretha Kohnk
<br />18. WAS DECEASED FVf -H IN J 5. ARMEFI FORCES' —T ---- - - - - -" -- - --
<br />19a INFORMANT NAME -- _ -- - - - - -' -'- -'-- --- - -- -
<br />Ves arc: or n'x J. war ntl r±il., of e,, e;;
<br />- - - -- ----- - - - - --
<br />Carol Fredrick
<br />191 INF RMANT A,tAILING ADi)RF SS - - "" —'--
<br />STREET OR R F () ryO.. CITY OR TOWN. STATE ZIP( -' --- - " -'- - - --'- —- - - --- -
<br />:�NE"A ALR . sIGNA,uRE x ICI o
<br />1 DATE 6£3824
<br />.- � 1 a METHOD OF DISPOSITO ^+ _ : it rt RD Cairo []E � -/� � ' 21 r. CEMETERY OR CREMA TORY y �� __. -.. —._ '�_1 `! / %a 0 West Lawn PR1 L 0 E - ME 21tl CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Tnf - Funeral Home ❑ Cremation ❑ Donauon Grand Island, NE
<br />222bb FUNERAL HOME ADDRESS STREET OR R.F.D NO CITY OR TOWN. STATE. ZIPS --
<br />P.O. Box 126 Wood River, NE 68883
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR T hi AND CII -
<br />PART I Interval between onset 1nr1 drat..
<br />I Cardio Pulmonary Arrest
<br />al - - -- Minutes _
<br />DUE TO OR AS A CONSEQUENCE OF - - -�- -- - - -- - - - --
<br />lot,, V,I between onset 11n r1, -.Iih
<br />oiLower lobe pneumonia approx. 10 days
<br />-- Dt1E TO OR AS A CONSFOUFNCF J /---------------- - - - - -- - - -- ' - -- - -- - - -- - - - --
<br />,o, 7AyT�dpva�nFccedd age and generalized age- related debility. Years
<br />PART, L11 l) rL L I.ANI. V FC4i10.NS tC�nd•11IS C�Ir .n...l!�q 1e Iheile�llYbil �t[¢Inte; pREG NANCY ALE PAST 3 MONTHS' 24 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL
<br />II "be S V Ccl 1. 1 L C EXAMINER OR CORONER PART
<br />chronic cerebrovascular insufficiency. 'i�A,�Sa, es �„ I�1I Yes N�
<br />- - - -- - -- ---- `----- _.—- �L —�. -_. Yes -❑ N:_ -. _ __
<br />-- — -- -
<br />26a Xh DATE OF INJURY Mo Da, Yr/ 26, HOUR OF INJURY 26d DESCRIBE HOW INJURY OCCURRED
<br />CtJDav Yr/ 26c HOUR OF INJURY 26tl DESCRIBE HOW INJURY n BURRED
<br />Acadent .)"ne!erm.red A
<br />-
<br />----
<br />S�cde I F .It1,ny 26 INJ''IRY AT WORK ?61 PLACE OF INJURY - ql home. farm street factory 2 -q LOCATION
<br />STREET ',R HFp NO r()R TOWN ST.+IF
<br />1 'IH,n,, lding etc /SpecdyJ
<br />Homede vem garrn y
<br />----
<br />es [I N!, [�
<br />z/a DATeoFDEATH M ...- _----- -_ —_ -- � --
<br />o D I rl - - -- 128A DATE SIGNED /Mn DaY v, r28h TIME OF DEATH
<br />;October 11, 2000
<br />276 DATE SIGNED iMo Dal- Yr 2/i: TIME OF ATH - - - - -- v -M-
<br />O 29c PRONOUNCED DEAD lMo Day Irl 28d PRONOUNCED DEAD /Hour/
<br />W' E s
<br />='10 17 -2000
<br />M I
<br />i 2rd he bell 01 I k, owledUe 7fatn ok .:/ '1 aI rime, dale nd glare and dug Io !ne z r 29e On Ine bass of exam.naro, and Or neest -galon rr my cp n nr 1 31 - ;,c"urrwl al
<br />'9 DID i a a ,fated �BUTTO date and olare and due Io the cause,I staled
<br />OBACC( Tt306 HAS ORGAN OR TISSU NATION BEEN CONSIDERED'
<br />AC�O USF C()N A 30h WAS CONSENT GRAN TFU'
<br />❑YE S ❑ NO LNKNOWN NO NO ❑ YES Ix >I NG
<br />1 - -- _ 'zY
<br />1 NAME AND ADDRESS OF CERTIFIER PHV $ICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEVi TVpe or
<br />�-f o en L. Hu sc: n M, Z (l (o ra d2 < # 4-D6 Q r,-,A d 15ILa^d / At E
<br />2a REGISTRAR 32b DATE FILED BV REGISTRAR lMo Day Yr/
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<br />WHEN THIS COPYCARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE "M-7, THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION,
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS -
<br />DATE OF ISSUANCE
<br />200100616
<br />OCT 2 3 2000 ASSISTANTSTATEmmisTiMA
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE XND-$VPPORT'
<br />VITAL STATISTICS --
<br />CERTIFICATE OF DEATH _
<br />'DECFDENT -NAME _.. __.- _._. —___ _
<br />FIRST MIDDLE LAS' T $EX 3. OATE OF DEATH Moom D.ar
<br />Carl NMN Harders Male _ October 11, 2000
<br />4 CITY AND STATE OF BIRTH ;/ /norm Uy�A. �anre c nrry 5a AGE - Last Birthday UNDER I YEAR UNDER 1 DAY 6 DATE OF BIRTH Mgnlh. Day 1"earl
<br />Wood River, Nebraska Vrs l(�2 b MOS DAYS 15c HOURS MINS Tune 8, 1908
<br />7 SOCIAL SECURTIV NUMBER � — " --
<br />Ba PLACE OF DEATN ---- -- ----- - - - - --
<br />506 -46 -0015 [X]
<br />HOSPITAL Ho,,
<br />b10alienl OTHER ❑ Nwsmq
<br />8b FACILITY Name //I IV, - 1r;fur;on. q 1 srreel t dnumb¢ /I ❑ ER Outpatient' ❑ Residence
<br />St. Francis Med Center ❑ ,DOA ❑ Other spe,fvl — ___ - --
<br />6c CITY TOWN OR LOCATION OF DEATH ed INSIDE CITY LIMITS 8e COUNTY OF DEATH - -- -- - --
<br />Grand Island Bl al
<br />Yes � No ❑
<br />9a RESIDENCE - STAIE ' 9b COUNTY 9e CITY. TOWN OR LOCATION 90 STREET AND NUMBER ;rnoudrng6;q� V 191 INSIDE CITY LIMITS
<br />Nebraska i Hall Grand Island 1405 HWY 34 G.I:
<br />Yes ' No ❑
<br />10 RACE (e.g., White Black Amencan Indian 11 ANCESTRY Ieq Italian, Mexican, German. etc) 12 MARRIED WIDOWED 13 NAME OF SPOUSE ;nw fe
<br />eK I ISoec .grve ma;den namel
<br />ISoe� Nl
<br />lte German NEVER DIVORCED
<br />MARRIED Alvira Krce er (de'" I___
<br />Ida USUALOCCUPATION /G;vekrnd0/workdonedunngmosr 141 KIND OF BUSINESS INDUSTRY 15 EDUCATION S eci
<br />o/workrng nle. even d reeredr p N only highest grade completetl)
<br />Elememary or Secondary r0 121 College i 1 -v o S
<br />16 FATHER -NAME FIRST MIDDLE LAST n MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Martin Harders Margretha Kohnk
<br />18. WAS DECEASED FVf -H IN J 5. ARMEFI FORCES' —T ---- - - - - -" -- - --
<br />19a INFORMANT NAME -- _ -- - - - - -' -'- -'-- --- - -- -
<br />Ves arc: or n'x J. war ntl r±il., of e,, e;;
<br />- - - -- ----- - - - - --
<br />Carol Fredrick
<br />191 INF RMANT A,tAILING ADi)RF SS - - "" —'--
<br />STREET OR R F () ryO.. CITY OR TOWN. STATE ZIP( -' --- - " -'- - - --'- —- - - --- -
<br />:�NE"A ALR . sIGNA,uRE x ICI o
<br />1 DATE 6£3824
<br />.- � 1 a METHOD OF DISPOSITO ^+ _ : it rt RD Cairo []E � -/� � ' 21 r. CEMETERY OR CREMA TORY y �� __. -.. —._ '�_1 `! / %a 0 West Lawn PR1 L 0 E - ME 21tl CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Tnf - Funeral Home ❑ Cremation ❑ Donauon Grand Island, NE
<br />222bb FUNERAL HOME ADDRESS STREET OR R.F.D NO CITY OR TOWN. STATE. ZIPS --
<br />P.O. Box 126 Wood River, NE 68883
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR T hi AND CII -
<br />PART I Interval between onset 1nr1 drat..
<br />I Cardio Pulmonary Arrest
<br />al - - -- Minutes _
<br />DUE TO OR AS A CONSEQUENCE OF - - -�- -- - - -- - - - --
<br />lot,, V,I between onset 11n r1, -.Iih
<br />oiLower lobe pneumonia approx. 10 days
<br />-- Dt1E TO OR AS A CONSFOUFNCF J /---------------- - - - - -- - - -- ' - -- - -- - - -- - - - --
<br />,o, 7AyT�dpva�nFccedd age and generalized age- related debility. Years
<br />PART, L11 l) rL L I.ANI. V FC4i10.NS tC�nd•11IS C�Ir .n...l!�q 1e Iheile�llYbil �t[¢Inte; pREG NANCY ALE PAST 3 MONTHS' 24 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL
<br />II "be S V Ccl 1. 1 L C EXAMINER OR CORONER PART
<br />chronic cerebrovascular insufficiency. 'i�A,�Sa, es �„ I�1I Yes N�
<br />- - - -- - -- ---- `----- _.—- �L —�. -_. Yes -❑ N:_ -. _ __
<br />-- — -- -
<br />26a Xh DATE OF INJURY Mo Da, Yr/ 26, HOUR OF INJURY 26d DESCRIBE HOW INJURY OCCURRED
<br />CtJDav Yr/ 26c HOUR OF INJURY 26tl DESCRIBE HOW INJURY n BURRED
<br />Acadent .)"ne!erm.red A
<br />-
<br />----
<br />S�cde I F .It1,ny 26 INJ''IRY AT WORK ?61 PLACE OF INJURY - ql home. farm street factory 2 -q LOCATION
<br />STREET ',R HFp NO r()R TOWN ST.+IF
<br />1 'IH,n,, lding etc /SpecdyJ
<br />Homede vem garrn y
<br />----
<br />es [I N!, [�
<br />z/a DATeoFDEATH M ...- _----- -_ —_ -- � --
<br />o D I rl - - -- 128A DATE SIGNED /Mn DaY v, r28h TIME OF DEATH
<br />;October 11, 2000
<br />276 DATE SIGNED iMo Dal- Yr 2/i: TIME OF ATH - - - - -- v -M-
<br />O 29c PRONOUNCED DEAD lMo Day Irl 28d PRONOUNCED DEAD /Hour/
<br />W' E s
<br />='10 17 -2000
<br />M I
<br />i 2rd he bell 01 I k, owledUe 7fatn ok .:/ '1 aI rime, dale nd glare and dug Io !ne z r 29e On Ine bass of exam.naro, and Or neest -galon rr my cp n nr 1 31 - ;,c"urrwl al
<br />'9 DID i a a ,fated �BUTTO date and olare and due Io the cause,I staled
<br />OBACC( Tt306 HAS ORGAN OR TISSU NATION BEEN CONSIDERED'
<br />AC�O USF C()N A 30h WAS CONSENT GRAN TFU'
<br />❑YE S ❑ NO LNKNOWN NO NO ❑ YES Ix >I NG
<br />1 - -- _ 'zY
<br />1 NAME AND ADDRESS OF CERTIFIER PHV $ICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEVi TVpe or
<br />�-f o en L. Hu sc: n M, Z (l (o ra d2 < # 4-D6 Q r,-,A d 15ILa^d / At E
<br />2a REGISTRAR 32b DATE FILED BV REGISTRAR lMo Day Yr/
<br />L�1W�1 n r, r o n D n n n
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