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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTM.AND' HUM,AN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE n%EgRA - si F DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY QRVITAL, RECORDSJ;
<br />DATE OF ISSUANCE
<br />08/04/2015
<br />LINCOLN, NEBRASKA
<br />20L;060i4
<br />STATE OF NEBRASKA CERTIFIC NT O DEA7H HUMAN SERVICES
<br />STANLEY 4, COOPER
<br />,ASSISI= �fiT},LI
<br />. - DEPAR'PME t HEALTH AND
<br />HYII' AN SERVICES
<br />1. DECEDENTS-NAME (First, Middle, Last, Suffix)
<br />Bemard Carl Harders
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Wood River, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506 -46 -0017
<br />eb. FACILITY-NAME (I not Mstitution, give street and number)
<br />Veterans Affairs Medical Center
<br />8c. CT' OR TOWN OF DEATH Mend* Zip Code(
<br />Grand Island 68803
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />94. STREET AND NUMBER
<br />715 West Stolley Park Road
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />Man5d, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First. Middle, Last. Suffix)
<br />Carl Herders
<br />11. EVER IN U.S. ARMED FORCES?
<br />(Yes, No, or Unk.) Yes 03/1
<br />Give dates of service N Yes.
<br />1/1953 - 02/09/1955
<br />15. METHOD OF DISPOSITION
<br />Daudet ❑lioness
<br />l cnmeaon ❑ememenient
<br />❑Re no.ei ❑othenspacdN)
<br />(disease or injury that Initiated death/
<br />Me event. inst .., DUE TO, OR AS A CONSEQUENCE OF:
<br />i n
<br />LAST
<br />26.
<br />TOBACCO USCOONTRIBUTE TO THE DEATH?
<br />YES ❑ NO ❑ PROBABLY ❑ UNKNOWN
<br />NA E. TITLE AND ADDRESS OF CERTIFIER (Type or Prim)
<br />TRAITS SIGNATURE
<br />6a. AGE-Last Birthday
<br />(Yrs.)
<br />84
<br />9b. COUNTY
<br />Hall
<br />15s. EMBALMER - SIGNATURE
<br />Not Embalmed
<br />al e o�n�c 6∎\\
<br />DUE TO, OR AS A NSEQUENCE O F:
<br />26a. HAS ORGAN OR TISSU
<br />❑ YES
<br />eb. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />9e. APT. NO.
<br />DONATION BEEN CONSIDERED?
<br />NO
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />MIl8.
<br />25233
<br />1. DATE OF DEATH (Mo.,Day,Yr.)
<br />July 25, 2015
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />July 9, 1931
<br />8a. PLACE OF DEATH
<br />HOSPITAL: ®Inpatle," QItlEE: 0 Hereby Home/LTC ❑ Hospice Facility
<br />❑ ERJOutpatient 0 Decedent's Home
<br />❑ DOA ❑ Othartspedty)
<br />14a. INFORMANT -NAME
<br />Donna Herders
<br />84. COUNTY OF DEATH
<br />Hall
<br />90. CITY (*TOWN
<br />Grand Island
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® Yea CI No
<br />10b. NAME OF SPOUSE (Met, Middle, Last, Suffix) N wife, give maiden name.
<br />Donna Kesner
<br />12. MOTHER•S•NAME (First. Middle, Malden Surname)
<br />Alvira Kroeger
<br />161. LICENSE N0.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />10c. DATE (Mo., Day, Yr.)
<br />July 28. 2015
<br />164. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />TXTYITOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />11. PART 1. Enter tee shin mavama • diseases, lepaies, or compiketto s -But dinette caused the death. DO NOT ester terminal events such as Cardiac arrest.
<br />respiratory arrest, or ventricular Ilbdnadon Without showing the etiology. DD NOT AESPEVIATE, Enter only one cause on • sea. Add additions( Pots 11vseaaery.
<br />IMMEDIATE CAUSE:
<br />bl `t n- Sea \_l Q \1 l,�oC4�cec Nt4 e \ ast
<br />17b. Zip Code
<br />68801
<br />IMMEDIATE CAUSE (Final
<br />glimpse or condition resulting
<br />in death)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Sequentially Ilan conditions. I
<br />any, leading to the cause listed
<br />MI Ott
<br />onset to death
<br />Enter the UNDERLYING CAUSE c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />onset to death
<br />d)
<br />18. PART 0. OTHER SIGNIFICANT CONDITIONS•Condfiors contributing to the death but not resulting M the underlying cause given M PART L
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ TES QU NO
<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 H pregnant *thin the past year
<br />ANNER OF DEATH
<br />Natur* ❑ Homicide
<br />nt ❑ Pending Investigation
<br />❑ Suicde ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑
<br />MIN (SPeely)
<br />210. WAS AN
<br />❑ YES
<br />❑ YES
<br />Y PERFORMED?
<br />NO
<br />214. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />tiNO
<br />22e. DATE OF INJURY (No., Day, Vr.) 22b. TIME OF INJURY 220. PLACE OF INJURY -At home, farm, street, factory, office building. construction site, etc. (Specify)
<br />m
<br />22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />❑ YES ❑ NO
<br />220. LOCATION OF INJURY - STREET & NUMBER. APT. NO.
<br />CITY/TOWN
<br />STATE ZIP CODE
<br />23b. DATE NED Igo., Day, Yr.(
<br />fit,.\\.;s ao
<br />23c. TIME OF DEATH
<br />ID'• lFi p.m
<br />230. DATE OF DEATH (1,90., Day, Yr.)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />246. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />m
<br />24e. On the basis of examination and/or investigation, In my opinion death occurred
<br />at the time, date and place and due to the cause(e) stated (Signature and Tftie)
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable 126a 1s NO ❑ YES
<br />291). DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />JUL 31 2015
<br />VT
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