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<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 OF ISSUANCE
<br />05/10/2017
<br />LINCOLN, NEBRASKA
<br />20. tF
<br />Noo tatonantieltNn post yeas
<br />14Pregostal Maim al death
<br />Wt prtenue, but Foram Tadao 42 days et dech
<br />0 Rol pageant, Sul prophant431Itta taboo bat.
<br />0 tin lbw it pteranlirimin the pal atar
<br />to' lo dealt
<br />1 DECEDENT'S-. NA ME (Fi r11 I.1ddII, !2 . MX 3.0441E OF OEM's.' N., Dry, ar.'t
<br />Johannes Henrich Harder Male April 9, 2005
<br />. 4, CITY R440 STATE Of TERRITORY OR FORMA COUNTRY OF BIRTH Oa, AGE4ial Birthday • Sh. UNDER 1 YEAR 5C UNDER 1 DAY E. DATE OP BIRTH IM12. 14i T4.1 :
<br />Ca fro Nebraska 5 411'4. September 3. 1„909
<br />{Yrs MOS. DAYS HOURS
<br />Sa RESIDENCE•STATE
<br />Nebraska
<br />get STREET 04NONUW8434
<br />Intwad1011as.3
<br />am, leaky lothatawatisai
<br />:
<br />beemetenksaifitopsdced&
<br />ItlAtFt? /A' WORN?
<br />LI
<br />V1414 LI NO
<br />STATE OF NEBRASKA - DEPARTMENT Of HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT 0 04163
<br />CERTIFICATE OF DEATH
<br />SECURITY MOWER 91:11JeMOF MAIN
<br />50748 ROAR ITM 0 RNYINI Ca1:13 U Nulirtg liNhictTC U Notpte
<br />Ib FACgl. IT 1 (41 not +/IAN Oro, rwc Creel Ord MU NNW)
<br />2806 N. St. Paul Rd.
<br />tic CITY OR TOWN OF DEATH DATUM ZpOode)
<br />Grand Island 68801
<br />2806 N. St. Paul Rd. 68801
<br />10.MM/a STATUS ATTIRE OFOCATH 1 Maisie d El Nkomo Elcorrico ;1,1 OF SPOUSE ins MOW, Laii, SON II 14. 14F4 maiden riarTta.
<br />mAM, but Worsted OWidg wod DivOrced D Marie H. Tagge
<br />1 f, FATHER'S-NAME (Far, Slialle, LEN, S&Iii 1) 12 NOTRE14'14A144E (rho.
<br />Hugo Harder Emma
<br />13. EVER IN OE. ARMED FORCES" piny dates al soawce 14 yea, i 14y. INFORNANSAINdE
<br />. no, ar trek.) NO ;, Marie Harder
<br />13. mrsso OF DISPOSIMOM 114A fAc 1 10. OCENSE NO.
<br />INtolid a DOnilkm B . , :f
<br />pc. 3 E '18d. TERY, CR ATORY OR ER 1191
<br />CE
<br />-- ca.,. ,lowN
<br />CA gros 30Ther ISpeoty)
<br />Wiegert Cemetery, Grand Island, Nebraska
<br />...Try FUNERAL AMOR MAME AMU MAY 1140 1412014141414 131114141, C414 01410140, SION
<br />. .4vingsten-Sondermann Ptmeral Home, 601 N. Webb Road, Grand I land, NE
<br />I. 14mer th 0 -dlul 96. irtwias. or camel nsk-11119 Owl& sauoad lfl 14,Al21. 012 NOT PPOKUMInellrolirif HIM 44 cardiac offlett,
<br />ret&IrANN NAV virsiculeu tIbilludua Maar ahoodot the Hasty DO 4411 ABBREVIATE. Era, only ono cauloan a IIrs,A14141411314141141141,141411 r&NagNAN.
<br />HANEDIATE CAUSE:
<br />isms:tan cAwstis.* 4 " )
<br />shavoNtervmenmoll9 14214F10, OR 14 SE04CE DP
<br />IRMA*
<br />DIJE 10. OR AS A CONS 01444C14 Cc:
<br />DUE TO, OR AS A CONSEQUENCE OF.
<br />4Y1
<br />114 PASTILOTHER SIONI Fr-4NT COND/11ORS-Ccadtheas wareibeteia ia dettoevinel amen wItseU.WIYINcely/f glYea
<br />014144JUR14 Day. Yr 274..
<br />22v. 0141414 1141414 140W 44
<br />LOCAT1ONOF IN0.00 VT11661 14 14U14141414. APT
<br />201703308
<br />Hall
<br />21a, MANNEROF DEATH
<br />, 5,111.100 Yinvile
<br />adicadariT° Pat.3413 I14watiOta21
<br />0 Saida ci Oosandi he deterwebe
<br />c..N4A+CNOFINJUR14.A1 hock rier&..ANNIt 41401141 y, teJecirid, o
<br />m
<br />CY OCCURRED
<br />0 ENnavaLleoz
<br />21b. IF TRARSPORTADON
<br />0 Dyyer..00MOM
<br />OPs&coart
<br />LEPtdeal(ar
<br />El Olam Smay(
<br />CI MY
<br />I M COUNTY Of DEATH
<br />B11
<br />90.CITN0RI0414N
<br />• Grand Island
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />9c. API. NO 91. DP CODE
<br />fl
<br />0%04,1
<br />ORmycSomiy!
<br />Ceded tO &el
<br />I meek to deaTi
<br />dibei to death
<br />14itesmEcirt
<br />Maiden Suonart'ai
<br />14E. RELAT1O NER1P TO DECEDENT
<br />Wife
<br />DA/E Day, Yr. 1
<br />April 12, 2005
<br />STATE
<br />1 1(1. Zig 14.D04
<br />68803
<br />rElp14rOA14AL
<br />1414 wASIODDISM.EIMMINER
<br />•
<br />DA CORONER CONTACTE0:::':
<br />U YES X NO
<br />YAIS AN AUTOPSY PERFORMED?
<br />014145 Xi°
<br />rid.WEREYMTIMSYFIrmir4OSAVYYAMV:::'
<br />CXIMPIXTE DAXIS CR DENNY "
<br />YES UHO
<br />230. DATE OF Otani Mo... Day, Yi ) ENt Th41E3i0 D (Mc 11
<br />., April 9, 2005 11 m
<br />rap Dive D TIN Am Yr ) ' 23c TIRE Of DEAT1H 2.40 PRONCONCED DEAD (Ma , Ova, Yi ) 2444.11NEPRONENN:EDDEAD
<br />7
<br />Jr (4 fr I 01:50 m
<br />d Ta !Mimi of layncledge &eel <mated al I he lane, deb arciolee* I i 5 24e. 01 ale hada 01 ixammtlyn amo memlommA ,n Iny °Omni mutt occured 11
<br />lava Oa to raiisalt) maisd (Sig/Alms and T(4A) V . _ ..g.y momm, chylc md pqacs and tab io 14 ■ causetel staled iStsnatia iliad 71114 t R
<br />DS =TWA= ce MINE DEATH? atia HAS onDiaotOR TiSSUE DOTIAMOY BEEN CONS! mb WAS CONSENT ORARTErrt
<br />X 3 14143 At40 a PBCOSABLY 0 UNKNOWN YES
<br />)(14 Nat App:icatdc NES
<br />27t LU41DP,E6P1E3 CEITTRIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI (141I13
<br />* Dr. Gordon J. Hrnieek, M.D., 729 N. Custer, Grand land, NE 68803
<br />FILED DY REG1STRAR (Ma., Day.,Yr4
<br />APR 1-3
<br />HI-IS-SI II AZ (5E651
<br />
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