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CD <br />z -� CL <br />r � m D o <br />Q`1 p zt CD N <br />Co <br />M CD <br />D <br />rr-, <br />r <br />r� F a cn CTS CD <br />A —,3 <br />.-« <br />Cn tA CTS O <br />The South Half (S1 /2) of Lot Three (3), all of Lot Four (4) and the North Half <br />(N1/2) of Lot Five (5), all in Block One (1), Second Addition to Cairo, Hall County, <br />Nebraska. <br />WHEN THIS COPY CARMES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HNlit i111C <br />SYSTEM, IT CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS 1 <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE . <br />MAY 2 4 2000 200004676 ASS/SIT- <br />LINCOLN, NEBRASKA HEALTHAND n <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SFAVICE$ F11 1NC$ t ED_ St <br />VITAL STATISTICS <br />CERTIFICATE OF DEATH - <br />I DECEDENT - NAME FIRST MIDDLE LAST <br />2. SEX <br />3, DATE OF DEATH IMOMin Day Year) <br />Albert Richard Lienburg <br />Male <br />May 15 2000 <br />4. CITY AND STATE OF BIRTH df not n USA.. name country) <br />5a. AGE -Last Birthday I <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /Month. Day Year) <br />(Yrs l 5b <br />MOS DAYS <br />5c. HOURS MINS <br />ras <br />90 <br />7 <br />December 1 , 1909 <br />7 SOCIAL SECURTIV NUMBER <br />Sa. PLACE OF DEATH <br />506 -22 -3920 <br />HOSPITAL ❑ Inpatient OTHER ® Nursing Home <br />❑ ER Outpatient ❑ Residence <br />8b FACILITY Name p /nolmstiluaon. give street and number/ <br />I Wedgewood Care Center <br />❑ DOA ❑ Other ISpeC4, <br />ill "—rf TMN aq LOCATOWOVOUTT4 - . —..._. - �_:,.• <br />ae: V#SQE CITYrL1161I — <br />aa. 60UPAY OF DEATH <br />Grand Island <br />Yea ® No ❑ <br />Hall <br />9a RESIDENCE - STATE <br />9b COUNTY <br />9c. CITY, TOWN OR LOCATION <br />9d. STREET AND NUMBER /Including Zip Code) <br />9e INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />800 Stover Dr. 68803 <br />1 Yes ® NO ❑ <br />t0 RACE - (e.g., White. Black American Indian. <br />11. ANCESTRY le .g.. Italian. Mexican. German, etc) <br />ANCESTRY <br />12. ® MARRIED ❑ WIDOWED <br />13 NAME OF SPOUSE df wife. give maiden name) <br />etc Sp¢c�lyl <br />Viite <br />German /Swedish <br />NEVER DIVORCED <br />Mayme Lowell <br />14a USUAL OCCUPATION (Give kind of work done during most 14b <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Speedy only highest grade completed) <br />of working life, even if refired/ <br />Mechanic <br />A iculture <br />Elementary o S dart' 10 121 College 11 4 or 5.1 <br />16 FATHER . NAME FIRST MIDDLE LAST 17 <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Fred Lea- <br />Alma Ruthstrom <br />_ <br />18 WAS DECEASED EVER IN US. ARMED FORCES? 19a.INFORMANT-NAME <br />IYes. no. or unk I (It yes give war and dales of services, <br />No Lemburg <br />1 1901 190 INFORMANT MAILING ADDRESS ;STREET OR R.F D. NO.. CITY OR TOWN. STATE. ZIPI <br />P.O. Box 18 Doni hat, NE 68832 <br />20 -ESIGNATURE 5 LICENSE NO <br />,v <br />21 a. METHOD OF DISPOSITION 21b. DATE 21c CEMETERY OR CREMATORY NAME <br />/ Z <br />A z1 <br />® Burial ❑Removal 5/18/2000 Loup Fork Cemetery <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />22a FUNERAL HOME -NAME I / <br />A fel Funeral Home <br />❑ Cremation E] Donal'°" Boelus, NE <br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIP) <br />411 West 11th P.O. Box 126 Wood River, NE 68883 <br />(ENTER ONL� gNNE/C�AUSE PER LINE FOR Ial. Ib1, AND (cp Interval and death <br />r3 IMMEDIATE C/AL1&4k E <br />'between <br />�/onset <br />PART <br />, <br />Y vvL. <br />I / V C.`.7 U1kQ <br />l i� + `Q 1:; Cam• <br />DUE TO. AS A C NS OUENCE OF 7} —� 1 interval between onset and death <br />ID) y J� <br />OUE :fUAR ASA N OUENCE G'. Interval between onset and dealt, <br />(cl <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL <br />PART ` PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONERS <br />n U <br />(Ages 10 -541 Yes -- Ves No Yes No <br />21 <br />261b DATE OF INJURY /Mo.. Day YrJ <br />26c HOUR OF INJURY <br />26d. DESCR* c -/CW INJURY OCCURRED <br />Acc -dent Undelermmed <br />M <br />�-' Svude - ending <br />26e. INJURY AT WORK <br />26f. PLq CE OF INJURY -q� hom9. /arm, street. factory <br />26g. LOCATION STREET OR q F D. NO CITY OR TOWN STATE <br />r, <br />Hom�ade In -11gal <br />yes No <br />❑ ❑ <br />ottice bmltling. etc /Sreciry/ <br />27a DATE OF DEATH) IMO. Day <br />28a. DATE SIGNED fMo.. Day. YO <br />28b TIME OF DEATH <br />�Y}rh <br />3�i <br />M <br />27b DATE SIGNED /Mo. Day vr) <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD fMo. Day. Yr) <br />28d PRONOUNCED DEAD (Hour! <br />> <br />g <br />g <br />S— O <br />`� r• �V M <br />a <br />M <br />° <br />3 � <br />27d To the best of my knowledge the time. date and and due to the <br />28e. On the basis of examination and or investigation, In my opinion death Occurred at <br />place <br />causelsl stated. <br />;7;�l <br />the time. date and Place and due to the causefs) stated. <br />//I/ <br />IS� nature and Title ► V <br />fSi nature and Title) <br />29 DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a <br />S ORGAN OR TISSUE DONATION EEN CONSIDERED? 30.b <br />WAS CONSENT GRANTED? <br />YES ❑ NO F-1 UNKNOWN <br />❑ YES NO <br />❑ YES NO <br />31 NAME AN A )DRE S F CERTIFI R IPHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type a Prim) <br />RiclIarc rue ing , M. D. <br />. <br />L1= ­b ml' ^l, !' - 2116 W.,A Faidley #40Q Grand Island, NE 68803 <br />sea �eu1n 1 rwn / u! _ . ` ' _ I .uo. un, a r•,�o� o. _ . _ �n� loo. _wy w.w <br />