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<br />200002575
<br />RE: Lot One (1) of Lambert's Subdivision of a part of the NW1 /4 SE1 /4 of Section
<br />Ten (10), in Township Eleven (11), North, Range Nine (9), West of the 6th o
<br />P.M., Hall County, Nebraska
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEP
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEi:,(01T0RY FOR'-,,
<br />VITAL RECORDS. r`O?
<br />DATE OF ISSUANCE`aI'
<br />MAY Z5 IM STANLEY S: G 0"13 ER, R.I C, RCt
<br />LINCOLN, NEBRASKA BUREAU OF VI:T�r "TTr "
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS 85 14490
<br />CERTIFICATE OF DEATHLY ,-"
<br />DECEDENT -NAME FIRS MI LAST
<br />X
<br />DATE DEATH (Me., Day, Yr.)
<br />Emil Carl Wa
<br />M
<br />December 9, 1985
<br />RACE- (e.g., while. Black. American ORIGIN/DESCENT (e.g.,Nalien,Memicon, AGE- Lasr640"" UNDER I YEAR UNDER 1 DAY DATE Of BIRTH (Mo., Day, Yr.)
<br />Indian, oh.) (Specify) Canaan, oft.) (Specify) (Yr$.) S. DAYS HOURS; MINS.
<br />I0 60 March 11 1925
<br />White s. German 60. �. 6c. ,.
<br />CITY AND STATE OF BIRTH (If nel in U.S.A., CITIZEN OF WHAT COUNTRY MARRIED, NEVER MARRIED, NAME OF S ►O)SE (Nwih, give moiden native)
<br />nave" cevwlry) WIDOWED, DIVORCED (Specify)
<br />South Dakot U.S.A. Married ,.Dorothy Jean Thompson
<br />B. Fairfax 9. 10.
<br />SOCIAL SECURITY NUMBER
<br />USUAL OCCUPATION (Give kind of work done during most
<br />KIND OF BUSINESS OR INDUSTRY
<br />COUNTY Of DEATH
<br />e /werki�np life,. n fnti d)
<br />t 9;Ver *7
<br />Mobile Home Q 3Z
<br />113bManu,.a.
<br />Hall
<br />,z. 507 22 3973
<br />,s,. Metal 1
<br />CITY, TOWN OR LOCATION OF DEATH INSIDE CI: LIMITS HOSPITAL OR OTHER INSTITUTION -Nauru (If ne to either, IF HOS►. OR INST. In01icote DOA,
<br />O•tp +I-nr /Err. Rm� , Imp -n•nr (SV«iyl
<br />(Specify Yee or No) give /Me/ and number
<br />Grand Island 114c. Yes „d. VA Medical Center Ida. In atient
<br />„b.
<br />RESIDENCE - STATE COUNTY CITY, TOWN OR LOCATION STREET AND NUMBER INSIDE CITY LIMITS
<br />(Specify Yn er No)
<br />lisc. li3d.
<br />Nebraska ISb. Hall Grand Island 1623 E. 7th Street )seYes
<br />Isa.
<br />FATHER-NAME 1 MIDDLE LAST NE - MAIDEN NAME FIRST DIE 'AST
<br />dec. Carl Frederick Wagner , dec. Maria Krueger
<br />WAS DECEASED EVER IN U.S. ARMED FORCES? INFORMANT- NAME - RELATIONSHIP - MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, SIfflvl
<br />b 1
<br />(Yec, ne. •r ..J) (If ys, gi.• war and it.M. N wr.ice)
<br />,B.Yes IKC /9 -29- 50/9 -12 -52 gDorothy Wagner, Wife 1623 E. 7th Grand Island NE
<br />BURIAL, Cremation, Re"w"ILMIC CEMETERY OR CREMATORY -NAME LOCATION CITY OR TOWN STATE
<br />Dec. 12, 1985
<br />soo. Burial sob. sot. Westlawn Memorial Park sod. Grand Island Nebraska
<br />EM ALMER NATURE B LIC NSE NO FUNERAL HOME -NAME AND ADDRESS (STREET OR R.F.D. No., CITY W TOWN, STATE, LIP)
<br />sA fel- Butler- Geddes 1123 W. 2nd ..'Grand Island, NE.68801
<br />s,
<br />DA SIGNED (Mo. Day, Yr.) HOUR OF DEATH
<br />E DEA7e7r .,-Day,
<br />Ti
<br />aSO
<br />23a, ece 9, 1985 j$1 24o. sbb. M
<br />DATE SIGNED (Me., Day, Yr.) HOUR Of DEATH =}_=i PRONOUNCED DEAD, PRONOUNCED DEAD (Hour)
<br />..r S (Ma„ Day, Yr.)
<br />December 10 1985 123,. 9 :25 a M ukz 24c. 124d, M
<br />sab.
<br />i Te if.. best of sty kne. lad♦•, deab •ccarr d et the thns, 01-10 end place emit due 10 the E � Chi the basis of a^emMUtien end)« )- .osNgetien, in envy pWo. doetb eccerr• l at
<br />• csrasNs) stet d. J = the fine, dote o^d ples• and dw 10 We uuw(s) ea10d.
<br />v i /e. FPM•)
<br />/y (SiRnden end
<br />sa ,15ignaere and IiN•1
<br />NAME N ADDRE f CER NYSICIAN, CORONER'S ►NYSKIAN OUNTY ATTORNEY) (Type er Prim))
<br />Dormond E. Metcalf, M.D. VA Medical Center, 2201 N. Broadwell Grand Island NF. 688
<br />No REGISTRAR // DATERECEIVED BY REGISTRAR (Me., Day, Yr.)
<br />126b. DEC 13 1985
<br />s6a.lsigtieter-hire) ' •
<br />IMMEDIATE CAU E (ENTER ONl NE CAUSE PER LIPW FOR (a), (b), AND (c)) Intor•al bet— -sec and de.tb Or i
<br />PART
<br />Cerebral vascular accident 2 Days
<br />a,
<br />DU , OR A CONSEQUENCE Of: Int•r•e1 ►etw-ea onset end d..M
<br />a) Chronic obstructive pulmonary disease Years
<br />1Mervel b•Men awsec emit dwM
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(d
<br />PART H R S NIfKANT CONDITIONS- Coodittews c.- biboNwg 10 de-M bet mot related FART IR. IF FEMALE, WAS THERE A AUTOPSY AS CASE REFERRED TO MEDICAL
<br />PREGNANCY IN THE PAST S MONTHST (Specify Ye. « NO EXAMINER OR CORONER
<br />(30a.
<br />11 f sp r1TO1
<br />Yee O No ❑ se. No 12W9. jv�
<br />ACCIDENT, SUICIDE, HOMICIDE, UNDET., DATE OF MUURY (Mw, Day, Yr.) NOUN OF IWURY IMSCRISE HOW INJURY OCCURRED
<br />OR "HOMO INVESTIGATION. (Specify)
<br />�0►. 70c. M 30d.
<br />AT WOK - M arm. sheet. fedwy. LOCATION STREET O! B,P.D. Me. CITY a TOWN STATE
<br />PIMUNT
<br />Spewy, Yee es Ile) slow bv>ilie9. eel. ISP" y)
<br />704.
<br />) 1
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