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n <br />n <br />3 DATE OF DEATH M1111(" Dar Yea /I <br />M <br />C <br />Male <br />July 5, 2000 <br />m <br />N C:D <br />UNDER 1 YEAR <br />= D <br />6. GATE OF BIRTH lMOnfh. Flay Year/ <br />Ravenna, Nebraska <br />0 <br />= ► -� o _� <br />D <br />o <br />rra <br />N <br />tl S <br />7 SOCIAL SECURTIY NUMBER <br />8a PLACE OF DEATH <br />508 56 0424 <br />HOSPITAL: Inoabenl OTHER ❑ Nursnq HOrne <br />❑ ER Outpatient ❑ Resioence <br />\ M <br />C IS <br />ib 7C <br />8c CITY TOWN OR LOCATION OF DEATH <br />80 INSIDE CITY LIMITS <br />8e COUNTY OF DEATH _ <br />Omaha I <br />Yes ® No ❑ <br />rn rr. <br />oQ <br />-'e <br />o � <br />9b COUNTY <br />9c CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (Including Zip Codel <br />9e INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />(, <br />o <br />CD <br />Yes ❑ No <br />10. RACE - (e.g.. While Black American Indian <br />11. ANCESTRY le q Italian. Mexican. German, etc) <br />12. g3 MARRIED O WIDOWED <br />13 NAME OF SPOUSE I// w✓e qwe maiden name) <br />etc) IScecrtyl <br />White <br />(Specify) <br />American <br />. <br />LaDonna Moritz <br />!� ?a <br />Idb. KIND OF BUSINESS INDUSTRY <br />15 EDUCATION (Specify only highest grade completed) <br />'d working h /e. ev"""e <br />° 00 <br />Elementary or Secondary 10 121 College ;1 .d or 5 •, <br />Owner /0 erator <br />ff� <br />rn <br />M <br />D cx� <br />r X <br />O <br />Virgil _ Lembur <br />Jean Kasel <br />18 WAS DECEASED FVER IN US ARMED FORCES <br />19a INFORMANT NAME - - <br />ive <br />(Yes no or um, 111 ves g war and dates of services) Vietnam <br />(S nature and Title) <br />V\ <br />LaDonna Lemburg <br />:3 <br />r - � <br />N = <br />r-2. <br />❑ YES NO <br />❑ YES ❑ NO <br />03 CD <br />C7 <br />CD <br />Q8 <br />Index this death certificate against the following real estate: <br />Lot 20, having a lake front frontage of 75 feet, and <br />being or& <br />the East side of the Westerly portion of Kuester Lake, and <br />being on a part of the East Half of the Southwest Quarter•iri <br />Section Thirteen, Township Eleven North, Range Nine, West of the 6th P.M., in Hall County, Nebraska, such lot is as <br />shown on the plat in the possession of the Lessor. <br />WHEN THIS COPYCANUES THE RAISED SEAL OF THE NEBRASKA HEALTH AND <br />SYSTIK R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REG <br />THF^EBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS77W, <br />TYE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE / <br />AUG 4 2000 200102989, <br />ASSITr: <br />LINCOLN, NEBRASKA HEALTH AND f440-M., <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES j;NAN-EA5lD SMFPORT <br />VITAL STATISTICS _ -- <br />CERTIFICATE OF DEATH <br />+ DECEDENT - NAME FIRST MIDDLE LAST <br />2 SEX <br />3 DATE OF DEATH M1111(" Dar Yea /I <br />_ Terry AKA Jerry Lee Lemburg <br />Male <br />July 5, 2000 <br />T CITY AND STATE OF BIRTH ,ll not in USA.. name country) <br />5a AGE Last Birthday— <br />UNDER 1 YEAR <br />UNDER I DAY <br />6. GATE OF BIRTH lMOnfh. Flay Year/ <br />Ravenna, Nebraska <br />(Vr51 <br />52 <br />Feb. 20, 1948 <br />Sc HOURS MINS <br />7 SOCIAL SECURTIY NUMBER <br />8a PLACE OF DEATH <br />508 56 0424 <br />HOSPITAL: Inoabenl OTHER ❑ Nursnq HOrne <br />❑ ER Outpatient ❑ Resioence <br />86. FACILITY - Name (ll not msht~. give sheer and number) <br />Univ. of Nebr. Medical Center <br />❑ DOA ❑ other(Speofr <br />8c CITY TOWN OR LOCATION OF DEATH <br />80 INSIDE CITY LIMITS <br />8e COUNTY OF DEATH _ <br />Omaha I <br />Yes ® No ❑ <br />Douglas <br />9a. RESIDENCE - STATE <br />9b COUNTY <br />9c CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (Including Zip Codel <br />9e INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />1#73 Kuester Lake 68801 <br />Yes ❑ No <br />10. RACE - (e.g.. While Black American Indian <br />11. ANCESTRY le q Italian. Mexican. German, etc) <br />12. g3 MARRIED O WIDOWED <br />13 NAME OF SPOUSE I// w✓e qwe maiden name) <br />etc) IScecrtyl <br />White <br />(Specify) <br />American <br />NEVER DIVORCED <br />❑MARRI <br />LaDonna Moritz <br />Ida 'USUAL OCCUPATION (Give knrdol work done during mos( <br />Idb. KIND OF BUSINESS INDUSTRY <br />15 EDUCATION (Specify only highest grade completed) <br />'d working h /e. ev"""e <br />° 00 <br />Elementary or Secondary 10 121 College ;1 .d or 5 •, <br />Owner /0 erator <br />Glass Com an <br />12 0 <br />16 FATHER NAME FIRST MIDDLE LAST <br />t 7 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Virgil _ Lembur <br />Jean Kasel <br />18 WAS DECEASED FVER IN US ARMED FORCES <br />19a INFORMANT NAME - - <br />ive <br />(Yes no or um, 111 ves g war and dates of services) Vietnam <br />(S nature and Title) <br />Yes 110 -7 -1965/ 2 -19 -1969 <br />LaDonna Lemburg <br />HOME. <br />—1) <br />HOME <br />_Kuester Lake Grand Island, Nebr <br />21a METHOD OF DISPOSITION I 21b DATE <br />I <br />❑ Banal ❑Removal 7-11-2000 <br />21 d. CEMETERY OR CREMATORY <br />Cremation ❑ Donation G <br />CITY OR TOWN. STATE, ZIPI <br />21c CEMETERY OR CREMATOPY NAME <br />Central Nebr. Cremati <br />-ATION CITY OR TOWN ST <br />)bon, Nebraska <br />1123 West Second Grand Island Nebraska 68801 <br />23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a). Ib6 AND (c)I Interval between onset and dealr <br />PART � <br />la_)- -- -- I '{ Stn L r ft r�,/' <br />T �i \ <br />DUE TO, ORA S A CONSEOIRNCE OF ,\ Interval be sari onset and dean <br />(b1 1 N -�-r A G� d rmiv - <br />DUE TO OR AS A CONSEQUENCE OF Interval between onset and deam <br />L��H�AC1Cf_C 1 <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related <br />PART <br />PART It IF FEMALE. WAS THERE A <br />2d AUTOPSY 25 WAS CASE REFERRED TO MEDICAL <br />H <br />PREGNANCY IN THE PAST 3 MONTHS? <br />E %AMINER OR CORONER I <br />Ages +0 -54I Yes No <br />r— <br />Ves No_� Yes ❑ No <br />25a <br />26b DATE OF INJURY %MO. Day Yr/ <br />26, HOUR OF INJURY T 26d. DESCRIBE HOW INJURY OCCURRED <br />L1 Accident Undetermined <br />M <br />Suicide Pendinq <br />26e INJURY AT WORK <br />26f PLACE OF INJURY - At home farm, street' factory <br />2139. LOCATION STREET OR R D NO .ITV OR TOWN S141E <br />Homicide investigation <br />Yes No <br />❑ ❑ <br />I office budding. etc lSpc ,l ,) <br />27a. DATE OF DEATH IMo. Day. Yr) <br />28a DATE SIGNED /Mo.. Day Yrl <br />28b TIME OF DEATH <br />M <br />y i k <br />27b. DATE SIGNED (MDay Yr.) 27c TIME OF DEATH <br />28c. PRONOUNCED DEAD IMo_ Day, Yr) <br />28d PRONOUNCED DEAD /Nowt <br />M <br />y <br />A g <br />° 00 <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 'o( invesngaaon. in my opinion deam occurred at <br />< <br />causefs) stated. <br />9 <br />the time, date and place and due to the causelsl stated. <br />ISi nature and Title) ► 0 1r '� <br />V <br />(S nature and Title) <br />1.9 DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' <br />30.b WAS CONSENT GRANTED' <br />❑ YES NO ❑ UNKNOWN <br />❑ YES NO <br />❑ YES ❑ NO <br />ivnrvr =tl ryp—mq <br />Mice el F. Sorrell, UNMC 983285 Nebraska Medical Center, Omaha, NE- 628198 -3285 <br />REGISTRAR <br />32b. DATE FILED BY REGISTRAR <br />JUL 1 1 <br />L5\ <br />O <br />