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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH
<br />SYSTEMi R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGIN41i
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL SIAM
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS -
<br />DATE OF ISSUANCE
<br />FEB LINCOLN, NE Ril Rd 200101404' ASMST
<br />HEALI ANB_HU!
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMA3^F S�
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEAIT,
<br />_10N.FILE WITH
<br />)ft .WHICH IS
<br />G
<br />MEE Q S TOR
<br />IECEDENT - NAME FIRST
<br />CD
<br />c> cn
<br />o_
<br />Otto
<br />C. Hauschild
<br />►—•
<br />o --.1
<br />;ITY AND STATE OF BIRTH (lI not n USA name counfryr
<br />,
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />2
<br />6. DATE OF BIRTH (Mont. Day Yearl
<br />Sb MOS DAYS
<br />M }.
<br />Ravenna, Nebraska
<br />rn
<br />1.1011
<br />March 22, 1919
<br />Suicide � Pending
<br />Homicide Investigation
<br />8a. PLACE OF DEATH
<br />O
<br />26g LOCATION STREET OR R F D NO. CITY OR TOWN STATE
<br />HOSPITAL. n Inpatient
<br />OTHER ❑ Nursing Home
<br />28a. DATE SIGNED (Mo Day Yr)
<br />28b TIME OF DEATH
<br />_
<br />FACILITY - Name lit nor Institution, give street and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other(Soecdy) —_
<br />CITY. TO..��W��N,,,O77R LOCATION,O�,F�aD7EATH
<br />1r7b. DAT SIGN/E -D lMo. Day. Yrl
<br />7+--� /v _
<br />O '�:
<br />8e COUNTY
<br />z frl
<br />O
<br />�',•'
<br />M
<br />LO7F..DEATH
<br />Hall
<br />D to
<br />9b COUNTY
<br />�E ,
<br />M
<br />9d STREET AND NUMBER preluding Zio Code)
<br />9e INSIDE CITY LIMITS
<br />Nebr ska
<br />T4 11
<br />Grand Island
<br />2326 N. Lafayette 68803
<br />Yes E No ❑
<br />,.
<br />n ANCESTRY leg Italian. Mexican. German, etcl
<br />N
<br />V
<br />t3 NAME OF SPOUSE win. give maiden name)
<br />etc.)(SpeuNl
<br />YYl l].te
<br />lSpeaN)
<br />AT ri
<br />;K
<br />DIVORCED
<br />Viet
<br />Rose L . K iha
<br />USUAL OCCUPATION /Give kind of work done during moss
<br />p
<br />..�.._;
<br />f =t
<br />15. EDUCATION ISpecdy only highest grade completed)
<br />niar Sec dary IC 121 College 11 d o, '
<br />�� �°ra�e
<br />co
<br />CA
<br />�
<br />s
<br />LAST
<br />17 MOTHER
<br />N
<br />Albert P.
<br />Hauschild
<br />MEE Q S TOR
<br />IECEDENT - NAME FIRST
<br />MIDDLE LAST -
<br />2.
<br />3. DATE OF DEATH (Month Day Yearl
<br />Otto
<br />C. Hauschild
<br />Maley
<br />January 26, 2001
<br />;ITY AND STATE OF BIRTH (lI not n USA name counfryr
<br />10 -54) Yes NO
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER' DAY
<br />6. DATE OF BIRTH (Mont. Day Yearl
<br />Sb MOS DAYS
<br />Sc.HOUR$ MINS
<br />Ravenna, Nebraska
<br />Vrsl III
<br />1.1011
<br />March 22, 1919
<br />IOCIAL SECURTIY NUMBER
<br />Suicide � Pending
<br />Homicide Investigation
<br />8a. PLACE OF DEATH
<br />261 office buOF IN�URY �S�NP, farm. street, factory
<br />26g LOCATION STREET OR R F D NO. CITY OR TOWN STATE
<br />HOSPITAL. n Inpatient
<br />OTHER ❑ Nursing Home
<br />28a. DATE SIGNED (Mo Day Yr)
<br />28b TIME OF DEATH
<br />❑ ER Outpatient ❑ Revde-
<br />FACILITY - Name lit nor Institution, give street and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other(Soecdy) —_
<br />CITY. TO..��W��N,,,O77R LOCATION,O�,F�aD7EATH
<br />1r7b. DAT SIGN/E -D lMo. Day. Yrl
<br />7+--� /v _
<br />go INSIDE CITY LIMITS
<br />8e COUNTY
<br />,Gra Nl t - Islr�nd
<br />Zjd To the best Of my krlowled death oc�.n at d e antl pia and due 1 e
<br />Causelsl stated. , '
<br />IS. nature antl Title) ► ACA
<br />Yes © No ❑
<br />r DID TOBACCO USE CONTRIBUT5.TO THE DEATH'
<br />❑ YES NO ❑ UNKNOWN
<br />LO7F..DEATH
<br />Hall
<br />RESIDENCE - STATE
<br />9b COUNTY
<br />9c CITY. TOWN OR LOCATION
<br />9d STREET AND NUMBER preluding Zio Code)
<br />9e INSIDE CITY LIMITS
<br />Nebr ska
<br />T4 11
<br />Grand Island
<br />2326 N. Lafayette 68803
<br />Yes E No ❑
<br />RACE (e.g.. White. Black. American Indian
<br />n ANCESTRY leg Italian. Mexican. German, etcl
<br />12. ® MARRIED
<br />❑WIDOWED
<br />t3 NAME OF SPOUSE win. give maiden name)
<br />etc.)(SpeuNl
<br />YYl l].te
<br />lSpeaN)
<br />AT ri
<br />NEVER
<br />MARRI
<br />DIVORCED
<br />Viet
<br />Rose L . K iha
<br />USUAL OCCUPATION /Give kind of work done during moss
<br />tab KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION ISpecdy only highest grade completed)
<br />niar Sec dary IC 121 College 11 d o, '
<br />�� �°ra�e
<br />workmp Irle.p,-yen it rGh/edl
<br />Elea '{-�- i t rator
<br />Maintenance
<br />FATHER - NAME FIRST MIDDLE
<br />LAST
<br />17 MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Albert P.
<br />Hauschild
<br />Marie A. Ahrens
<br />WAS DECEASED EVER IN U.S. ARMED FORCES'
<br />Iga INFORMANT -NAME
<br />/Yes. no. or unk.) III yes. give war and tlates nt services/
<br />No N A
<br />Rose L. Hauschild
<br />, INFORMANI MAILINU AUUHt55 Ibl Htt1 VHH1U rvV.I'll —1 inmi Jinn. ,,,
<br />EMBALMER - SIGNATURE 8 LICENSE NO 21a METHOD OF DISPOSITION 21b. DATE 21C CEMETERY OR CREMATORY NAME Service
<br />Not Embalmed ❑ ❑ Removal Jan. 26, 2001 Central Nebraska Cremation
<br />I. FUNERAL HOME NAME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Godberson Mort ❑x Cremation ❑ 00rat'lin Gibbon, Nebraska
<br />1 FUNERAL HOME ADDRESS (STREET R R.F D NO CITY OR TOWN STATE. ZIP)
<br />719 Front St., PO Box 10, Gibbon, Nebraska 68840
<br />IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a) . Ibl. AND Icil Interval between onset — -all
<br />PART C
<br />lal
<br />DUE TO.OR AS A CONSEQUENCE OF Interval between onset Arlo math
<br />(b) ("1 a+C - r.-i7z
<br />- DUE TO.OR AS A CONSEQUENCE OF .. - Interval between onset a,, nears
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A
<br />A OPSY
<br />WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />AMINER OR CORONER'
<br />II
<br />10 -54) Yes NO
<br />Vey No
<br />Yes No
<br />Vr)Ages
<br />a
<br />25b DATE OF INJURY IMO. Day. Yr)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident � Undetermined
<br />M
<br />Suicide � Pending
<br />Homicide Investigation
<br />26e INJURY AT WORK
<br />Yes ❑ No ❑
<br />261 office buOF IN�URY �S�NP, farm. street, factory
<br />26g LOCATION STREET OR R F D NO. CITY OR TOWN STATE
<br />20 DATE OF DEATH IMO Day. Yr)
<br />28a. DATE SIGNED (Mo Day Yr)
<br />28b TIME OF DEATH
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<br />1r7b. DAT SIGN/E -D lMo. Day. Yrl
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<br />Uc. TTIIME OF DEATH ,T,
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<br />28c. PRONOUNCED DEAD /Mo.. Day. Yr)
<br />28d. PRONOUNCED DEAD (Noun
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<br />Zjd To the best Of my krlowled death oc�.n at d e antl pia and due 1 e
<br />Causelsl stated. , '
<br />IS. nature antl Title) ► ACA
<br />28e. On the basis of examination and or investigation, m my opinion death occurred at
<br />the time. date and place and due to the Causelsl stated.
<br />, IS. nature and Title ►
<br />r DID TOBACCO USE CONTRIBUT5.TO THE DEATH'
<br />❑ YES NO ❑ UNKNOWN
<br />3Ve HAS ORGAN OR TISSUE DONATION BEEN NSIDERED7
<br />❑ VES NO
<br />Xb WAS CONSENT GRANTED'
<br />❑ YES NO
<br />NAMt ANU AUUHtbb UC U" I II-Itn lrni bA.IArv. 1—ni —H 11rJlVwn— U—niIr nI.vn rI Iryv -""r.(
<br />Kannt- h T.- V ?it-P1 rim.. 2116 W. Faidlev #400, Grand Island, Nebraska 68803
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