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WHEN THIS COPYCARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND H_ UMAN SERVICES <br />SYSTEK IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL, QW � 11VH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT /SIIir _ IS ` <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE X✓ ''!, <br />AUG 4 2000 EFSP M_ <br />'200102428 A i r <br />LINCOLN, NEBRASKA HEALTHAN646=': , VY& <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN �txyr.XS M�iTCriAND�5(RPORT <br />VITAL STATISTICS _. <br />_ CERTIFICATE OF DEdTH; = <br />DECEDENT - NAME FIRST MIDDLE LAST 2 SEX , 3 DATE OF DEATH /Month Dav Year) <br />Terry AKA Jerry Lee Lemburg Male July 5, 2000 <br />CITY AND STATE OF BIRTH lent d US.A.. name country/ 5a. AGE -Last Birthday UNDER I YEAR UNDER I DAY 6- DATE OF BIRTH (Month Day. Year) <br />lyrs I 5b. MOS I DAYS 5c. HOURS MINS <br />.1avenna, Nebraska <br />SOCIAL SECURTIV NUMBER <br />508 56 0424 <br />FACILITY Name (emNnslawon, give street and number) <br />Jniv. of Nebr. Medical Center <br />C:': Y TOWN OR LOCATION OF DEATH <br />CM r'r7 <br />N � <br />c:) a <br />O C. <br />I-+ <br />C <br />N <br />C, <br />co <br />N <br />M = <br />Q <br />T- <br />O <br />1V <br />V <br />52 <br />1 <br />AUTOPSY <br />9c. CITY. TOWN OR LOCATION <br />�v <br />�iebraska <br />n <br />Cl <br />Grand Island <br />4 #73 Kuester Lake 68801 1 Yes ❑ No <br />HOSPITAL <br />O Inpatient OTHER <br />❑ Nursing Home <br />❑ WIDOWED <br />13 NAME OF SPOUSE 11f wde give maiden name) <br />M^ <br />❑ Residence <br />M <br />N <br />❑ DOA <br />ti <br />n cn <br />J INSIDE CITY LIMITS I <br />96: LDUNTY OF DEATH <br />Smcae U Pending <br />- -- <br />z <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />1 Homicide Investigation <br />_ <br />Elementary or Secondary 10 -12) College I 4o, i <br />:3 <br />z <br />b <br />d ylOa Oi71 <br />_ <br />} <br />D <br />•0 <br />( .1r <br />u <br />a) •0 D 7 J <br />MOTHER <br />FIRST MIDDLE MAIDEN SURNAME <br />Virgil <br />�17 <br />Lemburg <br />=a <br />m <br />M <br />M fl <br />2 <br />N <br />27c TIME OF DEATH <br />28c. PRONOUNCED DEAD Wo.. Day. Yr.) <br />28d. PRONOUNCED DEAD /H-,1 <br />0 <br />° <br />r _ <br />- l <br />o <br />27d To the best of my knowledge death occurred at the time, date and place and due to the <br />28e. On the basis of examination and or investigation, in my opinion death occurred at <br />o <br />N <br />O <br />° = <br />the time. date and place and due to the causes) stated. <br />P!i [SI nature and Title) No V a il r <br />Signature antl Title ► <br />DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />30a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />` <br />O) <br />Z <br />❑ YES ❑ NO <br />M <br />3 <br />r M <br />�� �' <br />r <br />q� <br />C) <br />� <br />r--► <br />N <br />cni� <br />7C <br />N <br />...r.. <br />9 <br />co <br />An <br />WHEN THIS COPYCARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND H_ UMAN SERVICES <br />SYSTEK IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL, QW � 11VH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT /SIIir _ IS ` <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE X✓ ''!, <br />AUG 4 2000 EFSP M_ <br />'200102428 A i r <br />LINCOLN, NEBRASKA HEALTHAN646=': , VY& <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN �txyr.XS M�iTCriAND�5(RPORT <br />VITAL STATISTICS _. <br />_ CERTIFICATE OF DEdTH; = <br />DECEDENT - NAME FIRST MIDDLE LAST 2 SEX , 3 DATE OF DEATH /Month Dav Year) <br />Terry AKA Jerry Lee Lemburg Male July 5, 2000 <br />CITY AND STATE OF BIRTH lent d US.A.. name country/ 5a. AGE -Last Birthday UNDER I YEAR UNDER I DAY 6- DATE OF BIRTH (Month Day. Year) <br />lyrs I 5b. MOS I DAYS 5c. HOURS MINS <br />.1avenna, Nebraska <br />SOCIAL SECURTIV NUMBER <br />508 56 0424 <br />FACILITY Name (emNnslawon, give street and number) <br />Jniv. of Nebr. Medical Center <br />C:': Y TOWN OR LOCATION OF DEATH <br />CM r'r7 <br />N � <br />c:) a <br />O C. <br />I-+ <br />C <br />N <br />C, <br />co <br />N <br />M = <br />Q <br />T- <br />O <br />1V <br />V <br />52 <br />1 <br />AUTOPSY <br />9c. CITY. TOWN OR LOCATION <br />Feb. 20, 1948 <br />�iebraska <br />8a PLACE OF DEATH <br />EXAMINER OR CORONER' <br />Grand Island <br />4 #73 Kuester Lake 68801 1 Yes ❑ No <br />HOSPITAL <br />O Inpatient OTHER <br />❑ Nursing Home <br />❑ WIDOWED <br />13 NAME OF SPOUSE 11f wde give maiden name) <br />❑ ER Outpatient <br />❑ Residence <br />American <br />NEVER <br />❑ DOA <br />❑ Other /Speedy) <br />r. USUAL OCCUPATION (Grua kind of work dorre during most <br />J INSIDE CITY LIMITS I <br />96: LDUNTY OF DEATH <br />Smcae U Pending <br />- -- <br />of working lire. even d rekredl <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />1 Homicide Investigation <br />Yes No <br />❑ ❑ <br />Elementary or Secondary 10 -12) College I 4o, i <br />Owner/Operator <br />b <br />d ylOa Oi71 <br />_ <br />} <br />FATHER - NAME FIRST MIDDLE <br />•0 <br />( .1r <br />u <br />a) •0 D 7 J <br />RESIDENCE - STATE <br />9b COUNTY <br />AUTOPSY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER ffxkMkrglrp Code/ 9e INSIDE CITY uMITS <br />�iebraska <br />Hall <br />EXAMINER OR CORONER' <br />Grand Island <br />4 #73 Kuester Lake 68801 1 Yes ❑ No <br />RACE - (a g.. White. Black. American Indian. <br />t I. ANCESTRY (e.g.. Italian. Mexican. German, etc/ <br />12. MARRIED <br />❑ WIDOWED <br />13 NAME OF SPOUSE 11f wde give maiden name) <br />etc.) Specify) <br />White <br />(Spec'N) <br />American <br />NEVER <br />DIVORCED <br />LaDonna Moritz <br />r. USUAL OCCUPATION (Grua kind of work dorre during most <br />M <br />14b. KIND OF BUSINESS INDUSTRY <br />Smcae U Pending <br />15. EDUCATION (Specify only highest grade completed) <br />of working lire. even d rekredl <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />1 Homicide Investigation <br />Yes No <br />❑ ❑ <br />Elementary or Secondary 10 -12) College I 4o, i <br />Owner/Operator <br />Glass Com an y <br />12 <br />FATHER - NAME FIRST MIDDLE <br />LAST <br />MOTHER <br />FIRST MIDDLE MAIDEN SURNAME <br />Virgil <br />�17 <br />Lemburg <br />Jean Kasel <br />[Yes no or unk lc V c y(If yes give war and dates of services) Viet nam <br />?s 10 -7 -1965/ 2 -19 -1969 1 LaDonna Lemburg <br />,INFORMANT MAILING ADDRESS (STREET OR RE NO., CITY OR TOWN. STATE. ZIP[ <br />4#73 Kuester Lake Grand Island Nebr. 68801 <br />SLoMER - SIGNATURE 8 LI SE NO 21 a. METHOD OF DISPOSITION 21b. DATE 21c CEMETERY OR CRI <br />El 8unal ❑ Remoyel 7 -11 -2000 Central N <br />I. F ERAL HOME - N 21d. CEMETERY OR CREMATORY LOCATION Of <br />Lpfel-Butler-Ge4s UCrematlon ❑Donation Gibbon Nebr <br />FUNERAL HOME ADDRESS STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP[ <br />1123 West Sec <br />IMMEDIATE CAUSE <br />PART <br />A �j y- �o I� % ' \ ' <br />DUE TO. OR AS A CONSEO NCE OF <br />.40_ _ - 1 _i+r A -- a <br />WE TO. OR AS A CONSEQUENCE OF <br />ICI L L\r\r-\IQC tS <br />s <br />lal. (b). AND toll <br />44 y % 4 u 1Y. � f. ra 4j <br />� a� o •r+ <br />Q4-[ Tn L) <br />r f� -Ip -rloto a <br />0Q) z x a, <br />Cr � +J <br />Co <br />0 <br />En a) "it �0 <br />Ofar, Id qq <br />j 0 Nag <br />-- — 4 0 O JJ a) 4 <br />y o � M 41 <br />0O b -,,q C,I k0 b >a <br />NHa) a o <br />tw 4J 1:0 <br />4.1 rd W Wq JA-) -rl to <br />.0044 o a <br />4.3 ri O E+ a) <br />rdN�O 4 .. <br />.mation a�4J %4 <br />STATE _ .0 q a N �i ) to o <br />O k 44JJ v <br />— � q °.J ' a - to 1 <br />-H tow vmx to <br />a) O a) to to <br />C,4 ,Q 9 to a) <br />44 )H a) id to <br />I Interval between onset and dean 4-) '0 ri -rl C. to <br />o Ow In q -H ai o <br />aroox0zza <br />I <br />I Interval bgreen onset antl Beam <br />I �j'7 �'''� <br />v v <br />I <br />10 <br />OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not related PART <br />III IF FEMALE. WAS THERE A <br />AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />II <br />IN THE PAST 3 MONTHS? <br />�24 <br />EXAMINER OR CORONER' <br />(Ages 10 -54) Yes No <br />Yes No <br />Yes D No <br />25b DATE OF INJURY (MO.. Day Yr.) <br />26C HOUR OF INJURY <br />126d. DESCRIBE HOW INJURY OCCURRED <br />Accident ❑ Undetermined <br />M <br />Smcae U Pending <br />26e. INJURY AT WORK <br />26f P CE pF INJURY - At home. farm. street. factory <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />1 Homicide Investigation <br />Yes No <br />❑ ❑ <br />o ce bu to rig etc tSpgfy) <br />27a. DATE OF DEATH (Mo.. Day. Yr) <br />28a. DATE SIGNED (Mlo., Day Yr) <br />28b. TIME OF DEATH <br />M <br />75 - <br />8+ i a <br />27b DATE SIGNED (Mo.. Day Yr/ <br />27c TIME OF DEATH <br />28c. PRONOUNCED DEAD Wo.. Day. Yr.) <br />28d. PRONOUNCED DEAD /H-,1 <br />0 <br />° <br />r _ <br />- l <br />2U <br />.' 0 M <br />27d To the best of my knowledge death occurred at the time, date and place and due to the <br />28e. On the basis of examination and or investigation, in my opinion death occurred at <br />° <br />causelsl stated. C <br />° = <br />the time. date and place and due to the causes) stated. <br />P!i [SI nature and Title) No V a il r <br />Signature antl Title ► <br />DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />30a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />30.b WAS CONSENT GRANTED? <br />❑ YES NO ❑ UNKNOWN <br />❑ YES � NO <br />❑ YES ❑ NO <br />—r.v 1—..i , fryPeur 11 <br />Michael F. Sorrell, UNMC 983285 Nebraska Medical Center, Omaha, NE. r48198-3285 <br />i. REGISTRAR 32b. DATE FILED BY REGISTRATIN " �l ll JUL 1 <br />