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<br />STATE OF NEBRASKA
<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 />DATEOPM4SUANCE
<br />3/3/2017
<br />LINCOLN, NEBRASKA
<br />STAIR OF liERRASZA- DOPARIMAitif OF 111/41.111 ARE) IlUitAN SERV/CBS FThlikt/CE AND SUPPORT
<br />VITAL STAIRS/ICS
<br />CERTIFICATE OF DEATH 00 0 E 6 0
<br />IADOLE LAST 2 SEX 3 OATE OF DEATH 10,40mA Dee bast
<br />Kaspar, Jr. Male JanuisY 30, 2000 .
<br />Sa ae.yE - Lam &mar, [ UNDER 1 YEAR UNDER 4 CA! 6 DATE OF BIRTH My* Day YAK,:
<br />FOS I StI MOS i DOLVS Sc HOURS MINS
<br />' May 5, 1932
<br />Fairfax, South Da +
<br />kota 67 " '
<br />,
<br />ilF•f. - AtEoF0€01,
<br />1 pospn.A. Laj Inpalem OTHER [3 Newt Horne
<br />1 Rawa
<br />0 0
<br />ER Ceapabwe
<br />St. Francis Medical Center 1 - Ej DCA 0 Clew (Speedy(
<br />• CIT' !TWA OR LOCATION OF DEATH 1 Ed INSIDE CITY LIMITS ' 6 05 055444
<br />. gc Car TOM% OA LOCATE,: 'A's; SWEET AND A:PI—SEA (I.......M.--em AP Co*
<br />klECED691: NAME FEIST
<br />Tirt Laurel
<br />_ 9ve0l4S4 :mom eamoy
<br />7 SOLIAL $MAMA
<br />507-30-8743
<br />26 9 A,.." 0 .210.141^ 9AO SAVA .FAc
<br />Grand Island
<br />Sa RE SIOENCE - STATE 3 ft COUNTY
<br />•
<br />! 9. iNSIDE CITY WAITS
<br />Nebraska 1 Hall Grand Island i 220 S. Cedar 68801 ' 1 VII [(i l" O.
<br />Id ;(..C.E • 545 699.4 Mac. Aetancan ;mean 41 AIJCESTRY V* 9 . eakan. Mewcan. Gonna.. me; ' 12 70/1 aic S0a,1*
<br />MAARiED r WIDOWED i3 105845 05 SPOUSE X.* 5044190491 ",..5044190491 iSpacAD I . Irk j ,..
<br />1 1, 4 .4 . A ER n DNORCED I . Mary Anne Roenfeldt
<br />Wbite American 0 0
<br />145 KIND OF BUSINESS INDUSTRY [ 15 Erik/CATION ISpeCIN (WY KAMM glade DAMMAM(
<br />11,1 USUAL OCCUPATION , Gp v kod a I ow i rionedunflg ahmt
<br />of nor04 Y.. erne I ',anal io.,,, college it 401 5.4
<br />Chef Restaurant f W GT ' a r T
<br />- . . . •
<br />IS FATt R. 6695 LAST 17 MOTHER . , FIRST
<br />... .... . IE FIRST MIDDLE
<br />• • '. • • • • . .• • ; -
<br />. .. ' ' .: - .Icini • Kaspar - • Ella
<br />, IS WAS DECIASED EVER IN U.S. ARMED FORCES? 196 INFORMANT - MAE
<br />.. (516 .o drunk( I (45.9 gee wa, ald dates dean...est
<br />Yes 11-26-1951/1-25-1954
<br />Igo eNcOAMANT MAILING ADDRESS (STREET OR RF 0. 100. 0(41 OR TOWik. STATE. 3151
<br />220 S. Cedar, Grand Island, Nebraska 68801
<br />20 EMBALMER - SIGNATURE f4 110. 2115 MEIRDENOF DISPOSITION 215 DATE 21c CEMETERY OR CREMATORY NAME
<br />5
<br />gE- MA 7 eZpiole er
<br />ElunN 0 immoral Jan. 31, 2000 ;NE. State Anatomical Board
<br />220 UNERAL F
<br />2Id CEMETERY 09 CREMATORY LOCATION CITY ON TOWN STATE
<br />Li.vingston-Sondermann 0 Ctelnation rib:teat.. Omaha, Nebraska . . •
<br />Alt LITERAL HOME ADDRESS (STREET OA RF.O. No.. CITY OR TOWN. STATE,2IPI
<br />. • • . .
<br />601 -.N. Webb - Road, Grand Island, Nebraska 688034050
<br />23 IMMEDIKE CAUSE
<br />c ' kattek •
<br />DI,..tE•T oft AS A CONSEOUENCE OF • Hatay* PROM
<br />Wg& '
<br />%
<br />DOE:AMOR ASA CONSEOUENCE OF
<br />OTHER SIGNIFICANT CONDITIONS - Ccodemew conettang to the death de no mimed PART in IF FEMALE. WAS THERE A
<br />PART - ' 24 AUTOPSY • 25 WAS CASE 0451D TO MEDICAL
<br />' PAEGNANCY IN DIE PAST 3 MONTI/P •- .... 4' EXAMINER OR CORONER'
<br />, . ()Vas 10-541 Yea ri No 0 ,-. ri Nc 1 Yea
<br />- . . ."—}
<br />164 : 26b DATE OF INJURY IMa. Day Yr) 26c 44009 05 INJURY 26d. DESCRIBE ROW INJURY OCCURRED
<br />n Acc,dero E] UndeNonned
<br />• M
<br />O Sue.* 1:i Pencmg
<br />O .....,,ov .
<br />,I00
<br />275 DA/E OF DEATH Imo Day Yr(
<br />26e INJURY AT WORK
<br />Yes 0 No 0
<br />r- YES 0 NO 0 1.11■KNOV/N
<br />:■••■•.\•
<br />201702830
<br />261 17gEgiffZir (204 ol.o 90694
<br />A 4 1 - - 3r) - Qcor,
<br />27L DATE SIGNED lato Day Yr I 27c TIME 05 055444
<br />I ... ,-
<br />.15 v a --%- ey.N- - aps
<br />2 2141 TOM! IMMO my knowledge dash occ. Or ImA. dma and place and due to the
<br />r
<br />054410 0443 ;
<br />Illa
<br />.". (Sepatwe and TOM lk 4".4111Peoi • —(w .. ...0
<br />29 CID • °SAC uSE cosTnetrre TO H" 301
<br />MaryAnne Kaspar
<br />(ENTER ONLY ONE CAUSE PER ONE FOR ;at ;el 90441411 .3
<br />269 LOCATION
<br />Oar 4')
<br />. . vEs 1+915 r YES riEhg,
<br />31.114141EAW 5(0041.405 CF.RTEIER (PHYSICIAN CORONER 5 PHYS3E9N OR COUNTY ATTORNEY) )75)2e/teM.
<br />4 LCtaR..k• L ‘AcketSe kf'(1 EA;cAir,, ke - c.4114 kic .CA 3
<br />KG.„„44, , • (Mir FILED SY FIEGISTRAK vt(
<br />F113 3 2000
<br />STANLEY4 COOPER
<br />ASSISTAI4Lt STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />MIDDLE
<br />. MAJOEN SURIIIMAE
<br />• BenCiti!:1
<br />28c PRONOUNCED DEAD ;AA 04. 01 2110 P8C43(4.54( 13 DEA) etc.( "
<br />2611 4445 05 DEATH . ;
<br />1
<br />269 On the baps oIekarrnal.. .04 0' awes/9mo, opwon mem occanag 4 ,
<br />. ' mkt dale and place and am t ARNO . . c:)
<br />4 .
<br />HAS ORGAN OA TISSUE DONATION SEEN CONSIDERED' .305 WAS 0ONSE941 GRANTED' • ••••• • ; t
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