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MEN MS COPY CARRIES TIE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEAB R SKA HEALTH THE BELOW TO BE A
<br />THE NEBRASKA H TRUE COPY OF THE ORIGINAL RECORD ON FILE WIT/{
<br />EALTH AND HUMAN SERVICES SYSTEAC VITAL STATISTIK:S $L=CTIO� yyHl�{ /S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS -
<br />OFI
<br />LINCOLN, NEBRASKA AiIANT $TS
<br />HEALTHAN $
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND B& - + _ _
<br />VITAL STAIIS17CS
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<br />FIRST MIDDLE LAST
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<br />QfEREATH /Month Day yearl
<br />Judy Ka Fill' er
<br />iTATE OF BIRTH Ill rat k1 U5.A.. name county/ F = =arch 29 , 1998
<br />Sa. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /M, Day Year)
<br />d Island, Nebraska "rsI �r_ 5b. MOS ; DAYS 5c. HOURS' MIN$
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER Outpatient
<br />❑ DOA
<br />SIDE CITY LIMITS
<br />vi arr Q'-
<br />9a. RESIDENCE -STATE 9b COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />Nebraska Hall Grand
<br />10. RACE - (e.g., While. Black. Amencan Indian. 11. ANCESTRY I s land
<br />leg. Ian. Mexican, German, act
<br />'IC .I IScecdyi ISceuiyl IC MARRII
<br />Wh NEVER
<br />14a. USUAL OCCUPATION /Gne kind of work done drninq most ^ _ MA I
<br />of working life, even it retkedl ! 14b. KING OF BUSINESS INDUSTR i
<br />16. FATHER -NAME
<br />FIRST
<br />MIDDLE LAS 77 MOTHER
<br />(Dec.) Charles NMT Pokorney
<br />IB WAS DECEASEC EVER ry U.S. ARMED FORCES? -
<br />IYes. no or unk t 9a. INFORMANT -NAME
<br />No I 111 Yes give war and dales of serviced
<br />9D INFORMANT N/A na I P T.'l 1 7 n
<br />MAILING ADDRESS ISTREET 11-11111) . NO. CITI OR TOWN STATE. ZIP,
<br />20
<br />Kleine Funeral Home
<br />�. FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO. CITY OR
<br />3213 W. North Front St., Gr
<br />IMMEDIATE CAUSE
<br />PART
<br />March 14, 194
<br />OTHER: ❑ Nursing Home
<br />® Residence
<br />❑ Other /Specrlvl
<br />a
<br />9d. ST,RIEET AND NUMBEIR5/lnclud' Zp Code/ �91e I NSIDE CITY LIMITS
<br />❑ WIC East t 13 NAME OF S. _,, 618801 e, p'va maiden name No ❑
<br />DIVORCED Dale Fillinger
<br />39 15 EDUCATION IS_t, only highest grade completed)
<br />Elementary p Secondary 10 12, College n -4 or 5-I
<br />1 'f>_L ..._. � e9
<br />[la. METHOD OF DISPOSITION , 21b. DATE
<br />21c CEMETERY OR CREMATORY NAME
<br />® Burial ❑ Rempval p, r • 2 1998 Grand Island C' t CREMA Cenlet rti
<br />21tl CEMETERY OR TORY LOCATION e
<br />CITY OR TOWN STATE
<br />Cremation ❑ Donanor. �
<br />;TATE, ZIP, Grand Is
<br />Nebraska
<br />Island, Nebraska 68803
<br />DNLY ONE CAUSE PER LINE FOR fat. (b), AND Ici,
<br />I I lmerval between ousel and death
<br />(al I
<br />DUE TO. OR AS A ONSEOUENCE OF
<br />naknoxim-
<br />Ibl I
<br />Interval between onset and death
<br />DUE O OR AS A
<br />d
<br />Interval between onset and neam
<br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death Our nil related
<br />II PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY IN THE PAST 3 MONTHS7
<br />EAAMINER OR CORONER
<br />26a 26b. DATE OF INJURY (Ages 10 -541 Yes No yes No
<br />lM�... Day Yc/ 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Yes No�__
<br />Accident Undelermmed
<br />Suicide EJ Pending 26e. INJURY AT WORK M
<br />❑261. PLACE OF INJURY - ql home. farm. street. IactNv 269. LC
<br />Homlcioe mvesugatwn Yes o ice building, etc /Speciy/
<br />❑ N o ❑
<br />27a. DATE OF DEATH /Mo. Day. Yr.)
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<br />ED /MO. Dayayy yyr/
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<br />27b DATE
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<br />27c TIME OF DEATH
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<br />27d. To the best of my knowledge. death occurred at the time, Date and place ant due to the
<br />causelsl staletl
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<br />o �
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<br />s of exammati and or i
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<br />MEN MS COPY CARRIES TIE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEAB R SKA HEALTH THE BELOW TO BE A
<br />THE NEBRASKA H TRUE COPY OF THE ORIGINAL RECORD ON FILE WIT/{
<br />EALTH AND HUMAN SERVICES SYSTEAC VITAL STATISTIK:S $L=CTIO� yyHl�{ /S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS -
<br />OFI
<br />LINCOLN, NEBRASKA AiIANT $TS
<br />HEALTHAN $
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND B& - + _ _
<br />VITAL STAIIS17CS
<br />r - NAME CERTIFICATE OF DEATH
<br />FIRST MIDDLE LAST
<br />C_.) cn
<br />o -1
<br />C
<br />Z m
<br />--t
<br />C) -T1
<br />-Tt Z
<br />= M
<br />D W
<br />r �
<br />r n
<br />v�
<br />x
<br />n
<br />QfEREATH /Month Day yearl
<br />Judy Ka Fill' er
<br />iTATE OF BIRTH Ill rat k1 U5.A.. name county/ F = =arch 29 , 1998
<br />Sa. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /M, Day Year)
<br />d Island, Nebraska "rsI �r_ 5b. MOS ; DAYS 5c. HOURS' MIN$
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER Outpatient
<br />❑ DOA
<br />SIDE CITY LIMITS
<br />vi arr Q'-
<br />9a. RESIDENCE -STATE 9b COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />Nebraska Hall Grand
<br />10. RACE - (e.g., While. Black. Amencan Indian. 11. ANCESTRY I s land
<br />leg. Ian. Mexican, German, act
<br />'IC .I IScecdyi ISceuiyl IC MARRII
<br />Wh NEVER
<br />14a. USUAL OCCUPATION /Gne kind of work done drninq most ^ _ MA I
<br />of working life, even it retkedl ! 14b. KING OF BUSINESS INDUSTR i
<br />16. FATHER -NAME
<br />FIRST
<br />MIDDLE LAS 77 MOTHER
<br />(Dec.) Charles NMT Pokorney
<br />IB WAS DECEASEC EVER ry U.S. ARMED FORCES? -
<br />IYes. no or unk t 9a. INFORMANT -NAME
<br />No I 111 Yes give war and dales of serviced
<br />9D INFORMANT N/A na I P T.'l 1 7 n
<br />MAILING ADDRESS ISTREET 11-11111) . NO. CITI OR TOWN STATE. ZIP,
<br />20
<br />Kleine Funeral Home
<br />�. FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO. CITY OR
<br />3213 W. North Front St., Gr
<br />IMMEDIATE CAUSE
<br />PART
<br />March 14, 194
<br />OTHER: ❑ Nursing Home
<br />® Residence
<br />❑ Other /Specrlvl
<br />a
<br />9d. ST,RIEET AND NUMBEIR5/lnclud' Zp Code/ �91e I NSIDE CITY LIMITS
<br />❑ WIC East t 13 NAME OF S. _,, 618801 e, p'va maiden name No ❑
<br />DIVORCED Dale Fillinger
<br />39 15 EDUCATION IS_t, only highest grade completed)
<br />Elementary p Secondary 10 12, College n -4 or 5-I
<br />1 'f>_L ..._. � e9
<br />[la. METHOD OF DISPOSITION , 21b. DATE
<br />21c CEMETERY OR CREMATORY NAME
<br />® Burial ❑ Rempval p, r • 2 1998 Grand Island C' t CREMA Cenlet rti
<br />21tl CEMETERY OR TORY LOCATION e
<br />CITY OR TOWN STATE
<br />Cremation ❑ Donanor. �
<br />;TATE, ZIP, Grand Is
<br />Nebraska
<br />Island, Nebraska 68803
<br />DNLY ONE CAUSE PER LINE FOR fat. (b), AND Ici,
<br />I I lmerval between ousel and death
<br />(al I
<br />DUE TO. OR AS A ONSEOUENCE OF
<br />naknoxim-
<br />Ibl I
<br />Interval between onset and death
<br />DUE O OR AS A
<br />d
<br />Interval between onset and neam
<br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death Our nil related
<br />II PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY IN THE PAST 3 MONTHS7
<br />EAAMINER OR CORONER
<br />26a 26b. DATE OF INJURY (Ages 10 -541 Yes No yes No
<br />lM�... Day Yc/ 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Yes No�__
<br />Accident Undelermmed
<br />Suicide EJ Pending 26e. INJURY AT WORK M
<br />❑261. PLACE OF INJURY - ql home. farm. street. IactNv 269. LC
<br />Homlcioe mvesugatwn Yes o ice building, etc /Speciy/
<br />❑ N o ❑
<br />27a. DATE OF DEATH /Mo. Day. Yr.)
<br />�• ar Ictl UH H.F. D. NO
<br />F—�
<br />❑ ES UNKNOWN 30.a HAS ORGAN OR TISSUE DONATION BEEN CC
<br />Y ❑ NO .I 'f YES '� NO
<br />31 NAME AND AD El DRESS OF CERTIFIER 1PHVSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEY, hype dr Pr/ntl
<br />32a
<br />BY
<br />CITY OR TOWN STATE
<br />ZOO I IME OF DEATH
<br />2 ONOUNCED DEAD /HOUrI
<br />x+,•Ijyn� opinion death occurred at
<br />VT GRANTED1
<br />❑ YES NO
<br />iTRAR JI Day Yr./
<br />�( �,hrl,��, t •�'�'►� -d ,�� ,��. to f3� � � L'o-� - --
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<br />U,
<br />27b DATE
<br />'v wz
<br />n
<br />E d
<br />SIGNED (MO.. Da Yr/
<br />Y
<br />27c TIME OF DEATH
<br />$
<br />CED DEAD IMO. Day, Y,)>
<br />o
<br />"PRONOUNCEDDEAD
<br />27d. To the best of my knowledge. death occurred at the time, Date and place ant due to the
<br />causelsl staletl
<br />M
<br />s of exammati and or i
<br />_
<br />IS nature and Tule) ►
<br />-
<br />. and plac due c
<br />9 DID TOBACCO
<br />USE CONTRIBUTE TO THE DEATHS
<br />r.�_.
<br />F—�
<br />❑ ES UNKNOWN 30.a HAS ORGAN OR TISSUE DONATION BEEN CC
<br />Y ❑ NO .I 'f YES '� NO
<br />31 NAME AND AD El DRESS OF CERTIFIER 1PHVSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEY, hype dr Pr/ntl
<br />32a
<br />BY
<br />CITY OR TOWN STATE
<br />ZOO I IME OF DEATH
<br />2 ONOUNCED DEAD /HOUrI
<br />x+,•Ijyn� opinion death occurred at
<br />VT GRANTED1
<br />❑ YES NO
<br />iTRAR JI Day Yr./
<br />�( �,hrl,��, t •�'�'►� -d ,�� ,��. to f3� � � L'o-� - --
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