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I DECEDENT - NAME FIRST MIDDLE LAST Merle Dean Luft 2 - SEX Male 3 DATE OF DEATH IMO nth Day Yearl June 6, 2001 4 CITY AND STATE OF BIRTH Ill not in USA.. name country) Osceola, Nebraska 5a AGE - Last Birthday (Yrs.l 79 79 UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Month. Day. Year) October 15, 19(� 21 6b MOS ; DAYS Sc. HOURS MtNS 7 SOCIAL SECURTIY NUMBER 508 -14 -5672 8a PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER. al Nursing Home ❑ ER Outpatient ❑ Residence ❑ DOA ❑ Other /Spec,vl 8b FACILITY - Name 111 not Institution. give street and numbed Park Place Health Care /Rehab 28b. TIME OF DEATH 8c CITY TOWN OR LOCATION OF DEATH Grand Island 8d. INSIDE CITY LIMITS Yes ► j No ❑ Be. COUNTY OF DEATH Hall 9a. RESIDENCE - STATE Nebraska 9b. COUNTY Hall 9c. CITY. TOWN OR LOCATION Grand Island 9d. STREET AND NUMBER )Including Zip Code) 2619 W. 1st, 68803 9e. INSIDE CITY LIMITS Yes No 10. RACE - (e.g., White. Black. American Indian. n{{ etc( I S IaIlte W Il 11. ANCESTRY le.g.. Italian. Mexican. German, etc) I pec'NI American 12. f MARRIED ❑ WIDOWED �f ❑NEVE ❑DIVORC MARRIED 13. NAME OF SPOUSE 1/I wde. give maiden name) Ruth Swanson Ruth 14a USUAL OCCUPATION (Give kind of work done during most of working /i /e, even if retired) Sales Clerk 14b KIND OF BUSINESS INDUSTRY Retail Sales 15. EDUCATION (Specify only highest grade completed) Elementary or Sec n ry 10 -12) College it -4 0, 5 i IL 16. FATHER - NAME FIRST MIDDLE LAST Adam Luft 17 M OTHER FIRST MIDDLE MAIDEN SURNAME Violet Grossnicklaus 18. WAS DECEASED (Ye5 Yes: EVER IN U.S. ARMED FORCES? I 111 yep 7 - 25 12 -4 -1945 19a. INFORMANT - NAME Ruth Luft SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART & \/\ \ i PART III IF FEMALE. WAS THERE A PREGNANCY IN THE PAST 3 MONTHS (Ages 10541 Yes No ❑ 24 AUTOPSY } Yes ❑ No 7 25. WAS CASE REFERRED 70 MEDICAL EXAMINER OR CORONER? Yes No p 26a ri Accident . Undetermined r � J Suede U Pending U Homicide Invesugatlon 26b DATE F INJURY Mo.. Day. Yr.) 26c HOUR OF INJURY 1 26d. DESCRIBE HOW INJURY OCCURRED � M I 26e. INJURY AT WORK Yes N ❑ ❑ . farm. street. factory 261. PLAc b udd OF ing IN . J etc. (Spec - At home0y/ offi 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE 27a DATE OF DEATH (Ma Day L - v -,,,c..,(75, To be Complete.] by CORONER'S PHYSICIAN v. COUNTY ATTORNFY ONLY 28a DATE SIGNED /M0. Day Yr) 28b. TIME OF DEATH 28c. PRONOUNCED DEAD I MO.. Day. Yr) 28d. PRONOUNCED DEAD (Hour! M a 1 270. DATE SIGNED (Ma. Day. Yr) g ot (- 1\ - GI 8 °_ 27c TIME OF DEATH 1 . ? -cJ M 28e. On the basis 01 examination ano or investigation, in my opinion death occurred at the time. date and place and due to the causes stated. (Signature and Title) lo _ - 1 27d. To the best of my knowled e death occurred at the time, date and place and duo4o the 0300061 stated. 1 U�-/ �, Ali � (Signature and Title) ►� `��r"`LLL... 29 DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO M UNKNOWN 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES n NO 30 b WAS CONSENT GRANTED' ❑ YES UN() 19b INFORMANT WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVIC2 0 i•5 0 619 3 SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. ANLEY S. COOPER ASSISTANT STATE REGISTRAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HLIMAN SERVICES PENANCE AND SUPPORT VITALS S 01 0046r CERTIFICATE OF DEATH DATE OF ISSUANCE JUN 15 2001 ,2d EM$ALMER - SIGNATURE 8 LICENSE NO T 22a. FUNERAL HGME - NAME MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE ZIPI 2619 W. 1st, Grand Island, NE. 68803 Apfel- Butler - Geddes DUE TO, OR AS A CONSE UENCE OF ()l DUE TO. OR AS A CONSEOUENCE OF (c1 32a REGISTRAR /6,0 22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP) 21 a. METHOD OF DISPOSITION 21b DATE 1123 West Second, Grand Island, NE. 68801 (ENTER ONLY ONE CAUSE PER LINE FOR i a. tb). AND Id) 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY, i Tvpe or Pnntl Donald Wirth M.D. 2116 W. Faidley, Grand Island, NE. 68803 21c. CEMETERY OR CREMATORY NAME Burial ❑ Removal June 9, 2001 Grand Island Cemetery 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE ❑ Cremation ❑ Donaiior Grand Island, NE. Interval between onset and deal, 23. IMMEDIATE CAUSE PART \ al � ..� C a� ` rT n 1 V--P V C, v _ C r, �. r- ✓ I\ C - '� ,�.- N, - . �� t k 0 v` �. 32b DATE FILED BY REGISTRAR /Mo Day Yr) JUN 1 4 2001 Interval between onset and death Interval between onset and death