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6/14./2016
<br />LINCOLN, NEBRASKA
<br />1. DECEDENT - NAME FIRST
<br />4. : CITY AND STATE OF BIRTH. > (d riot in US A - A., name 0740101
<br />t .nc s ayi, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />333 -12 -1242
<br />8b. .FACILITY - Name > (y not irtsatufion, give street and number)
<br />St.. Francis Medical Center
<br />9a RESIDENCE - -STATE
<br />Nebraska
<br />16. FATHER - NAME : FIRST
<br />le. WA$CECEASEO EVER IN U.S. ARMED FORCES?
<br />(Yes, no, or unk.i (If yes. give war and dates of services)
<br />No
<br />26L.,BURIAL Cremelien.fie.
<br />Damian
<br />Bu ial
<br />Jr
<br />(DI
<br />26a ACCIDENT, SUICIDE, HOMICIDE, UNDET.
<br />1XkPENDING:INVESTIGATION (Spxiy)
<br />26e, INJURY AT WORK
<br />(SpeCtfy Yes Cr Net
<br />3214
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OE ISSUANCE
<br />R • .IGNA
<br />Matt
<br />M.
<br />DUE TO, OR AS A CONSEQUENC
<br />27d. To the best of my knowledge.
<br />causes) stated.
<br />((Signature and T48e(
<br />29a. DID TOBACCO USE CONTRIB
<br />YES NINO
<br />Christian NMI Dohmen
<br />9b. COUNTY
<br />200. DATE
<br />Hall
<br />8a. PLACE OF DEATH
<br />MIDDLE
<br />Aug . : , 19
<br />No. J137
<br />27a. DATE OF DEATH (Mo., Day. Yr.)
<br />AUGUST;6, 1991
<br />70. GATE SIGNED jMo., Day. Yr.)
<br />AUGUST 6, 1991
<br />260. DATE OF INJURY (Mo.,Day. Yr.)
<br />THE DEATH?
<br />❑ UNKNOWN
<br />201. PLACE OF INJURY - At bane, farm, street. lactoly,
<br />office building, etc. (Specify)
<br />27c. TIME OF DEATH
<br />urred at the time, date : • • • ace
<br />20 1603762
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS . .; - CERTIFICATE OF DEATH
<br />MIDDLE LAST
<br />5a AGE - Last Birlhda
<br />(Yrs.)
<br />75
<br />10. RACE- )e.g., Wflas. Slick, Ame+Ican Indian, 11. ANCESTRY le.g.,Italian, Mexican, Garman. etc )
<br />etc.) (Specter) (Speedy)
<br />Mite American 0
<br />14a USUAL OCCUPATION Ore *end of work 0008 during most
<br />01 working lithe. even d reared) �C
<br />Auto Mechanic
<br />OR A5,1CORSEO OF:
<br />( 'YLQ- '4 .c. Y
<br />HOSPITAL: >73 Inpatient 0 ER,Outpatlent ❑ DOA
<br />OTHER: ❑ Nursing Home ❑ Residence ❑ Other (Sperry)
<br />Sc. CITY. TOWN OR LOCATION OF DEAAT
<br />Grand Island
<br />140. KIND OF BUSINESS INDUSTRY
<br />Automobile 15\
<br />LAST
<br />Dohmen
<br />19. INFORMANT - NAk
<br />26c. HOUR OF INJURY
<br />UNDER 1 YFAR
<br />5b. >,MOS. t DAYS
<br />12: MARRIED.
<br />WIDOWED, DIVORCED (Speedy)
<br />Married
<br />17, MOTHER - MAIDEN NAME
<br />20c. CEMETERY OR CREMATORY - NAME.
<br />Westlawn Memorial Park
<br />22. FUNERAL HOME . NAME AND ADDRESS
<br />(ENTER ONLY ONE CAUSE PER LINE FOR (a). (b). AND lc))
<br />tcL
<br />OTHER SIGMFICANT CON XNIS - Conditions contributing to death but not relakeed 4 PART 1e IF FEMALE, WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />M
<br />269. LOCATION
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICAN, CORONER'S PHYSICAN OR COUNTY ATTORNEY) (Type or Print)
<br />28a
<br />30a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES QIO
<br />STREET OR R.F.D. NO.
<br />GATE SIGNED (Mo., Day. Yr)
<br />8d. INSIDE CITY LIMITS
<br />(Specify Val or Not
<br />Yes
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />29c. PRONOUNCED DEAD /Mo.. Day. Yr/
<br />STANLEY COOPER
<br />ASSISTA STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />91 0922'7
<br />2. SEX 13 DATE OF DEATH (Monet, Day, Year)
<br />Male Aug. 6, 1991
<br />I INIIFR 1 DAY 6. DATE OF BIRTH (Month, Day, .0 &)
<br />HOURS' MINS.
<br />July 20, 1916
<br />9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER (Including bp Cod.)
<br />Grand Island 1515 N. Kruse
<br />8e. COUNTY OF DEATH
<br />Hall
<br />13. NAME OF SPOUSE (H wife grve rn 0. Wny
<br />Ann T. Braun
<br />15, EDUCATION ISoecifv day tannest Watts conwesledl
<br />Elementary or Secondary (0-12) I Coesge (1-4 or 55 +1
<br />8
<br />FIRST MIDDLE
<br />Mary
<br />MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, ST...ITE. DPI
<br />Ann T. Dohmen -1515 N. Kruse -Grand Island, NE.68803
<br />200. LOCATION CITY OR TOWN
<br />Grand Island, NE.
<br />(STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP)
<br />Angel- Butler - Geddes 1123 W. 2nd, Grand Island, NE.68801
<br />edema between onset and dowel
<br />Interval bbetee Onaef4td WifieT.
<br />Interval between onset and MGM
<br />�7 - Fit - - CV's - r{- C'. y`.� ^'4 `/
<br />24. AUTOPSY
<br />(Specify Yes
<br />25. WAS CASE REFERRED MEDICAL
<br />NO EXAMINER Of9 CORONER?
<br />(Speedy Yes - Ot No)
<br />CRY OR TOWN ;;STATE:
<br />280. TIME OF DEATH
<br />ms s; $
<br />g 28e. On the bases of examination and!or invesirgawn. in my opnwn death =monad at
<br />E the time. date and place and due to the cause(s) stated.
<br />{ Signature and Tide)
<br />30b. WAS CONSENT GRANTED?
<br />YES
<br />S. F. Nabit M.D. 2444 Faidle , Grand Island, NE. 68803
<br />- - - -- 320. DATE FILED BY REGISTRAR ab. L1ay,Yrf
<br />auk 9
<br />INSIDE envoi/Ts
<br />(SPeca* Yaw or No)
<br />Yes
<br />LAST
<br />Sand
<br />STATE
<br />W
<br />w
<br />00
<br />
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