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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COPY, -
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT!- �`' ,''Tlc /
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSIT Ff1R
<br />VITAL RECORDS. �
<br />DATE OF ISSUANCE 200005076
<br />r r
<br />}AN 5 IM STANLEY S. COOPER;y�IRECTOR -` %�
<br />LINCOLN, NEBRASKA BUREAU OF VITAL STATISTT ;S?, 4
<br />STATE OF NEBRASKA - DE#' RTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH Q a
<br />I . DECEDENT -NAME FIRST MIDDLE LAST -- --
<br />2. SEX
<br />24. AUTOPSY
<br />1 DATE OF DEATH /Month. Day. Yee0
<br />Orin Ed ar
<br />Beeder
<br />Male
<br />December 8, 1989
<br />4. CITY AND STATE OF BIRTH (d not in U.S.A., name countryl
<br />Yea ❑ No ❑
<br />CD
<br />(Specify Yes gJvo
<br />(Spec
<br />1V0 l
<br />28a. ACCIDENT, SUICIDE, HOMICIDE, UNDET.,
<br />OR PENDING INVESTIGATION (specdy)
<br />126b. DATE OF INJURY (Mo.,Dey, Yr.)
<br />6. DATE OF BIRTH (Month, Day. Yearl
<br />-n
<br />Sc. HOURSI
<br />rn
<br />-
<br />(Yrs,)
<br />C-
<br />O n
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />57
<br />office building, etc. (Specify)
<br />October 15, 1932
<br />Y: AOGAL SECURITY NUM
<br />aa. P GF bF
<br />Tn
<br />HOSPITAL AO�Inpatiem ❑ ER: Outpatient ❑ DOA
<br />506 30 9014
<br />OTHER n N urw*Han. o I4i- "1 ❑ Older fspeeifyl
<br />8b. FACILITY - Name (if na inpitufion, give street and numberl
<br />N
<br />150
<br />8d. INSIDE CITY LIMITS
<br />M
<br />D
<br />En
<br />p
<br />(Specify Yes or Nol
<br />I
<br />rn 70
<br />Bryan Memorial Hospital
<br />Z
<br />-i M
<br />o1
<br />O
<br />CD
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />27d. To the best of my kn death occurred anN time, dam and place and due to the
<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 Islan +l•
<br />o
<br />ecif, Yes of
<br />(Yes NO)
<br />10. RACE - (e.g.. While, Black, American Indian,
<br />11. ANCESTRY (s.q.,ftalian, Mexican, German, slo.)
<br />12. (t4RRIED,NEVER MARRIED,
<br />13.
<br />NAME OF SPOUSE (ff wife, gwe maiden name)
<br />etc.) (specify)
<br />(Specify)
<br />f
<br />:;w
<br />O
<br />tin
<br />Married
<br />Bernice Franssen
<br />14a. USUAL OCCUPATION (Give Idnd of work done during most
<br />of sorting fife even d rehrsd)
<br />3
<br />lab. KIND OF BUSINESS INDUSTRY
<br />Elementary
<br />M
<br />rn
<br />X14
<br />or Secondary (0.12) Collage (1 -4 or 5•)
<br />1
<br />D W
<br />o
<br />12
<br />16. FATHER -NAME FIRST MIDDLE
<br />UST
<br />17. MOTHER - MAIDEN NAME
<br />FIRST MIDDLE LAST
<br />Charles
<br />V
<br />Hazel S ink
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />CJ 1
<br />C
<br />(Yes, no, or unk.) (it Yes, give war and dates d services)
<br />I
<br />8 O 03
<br />6 0
<br />I I
<br />K:7
<br />N Lafa ette Grand Island, NE
<br />20a. BURIAL, Cremation,Removal,
<br />20b. DATE
<br />2Dc. CEMETERY OR CREMATORY - NAME
<br />20d. LOCATION CITY OR TOWN STATE
<br />Donation
<br />-
<br />Cn
<br />N
<br />Dec 12, 1989
<br />O
<br />CD
<br />Grand Island, Nebraska
<br />21. EMBALMER 6 LICfX.SE NO. -L (gyp 8
<br />22. FUNERAL HOME. NAME AND ADDRESS
<br />(STREET OR R.F.D. NO., CITY OR TOWN, STAIgEPi 6880 1
<br />LIVINGSTON- SONDERMANN F.H.,
<br />505 W KOENIG, GRAND ISLAM
<br />y
<br />I Interval between onset and death
<br />',u Brainstem hemorrhage
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />�
<br />,
<br />IN
<br />I Interval between onset and death
<br />I
<br />I
<br />C1l
<br />v
<br />M
<br />O
<br />ti,
<br />n
<br />r
<br />4A
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COPY, -
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT!- �`' ,''Tlc /
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSIT Ff1R
<br />VITAL RECORDS. �
<br />DATE OF ISSUANCE 200005076
<br />r r
<br />}AN 5 IM STANLEY S. COOPER;y�IRECTOR -` %�
<br />LINCOLN, NEBRASKA BUREAU OF VITAL STATISTT ;S?, 4
<br />STATE OF NEBRASKA - DE#' RTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH Q a
<br />I . DECEDENT -NAME FIRST MIDDLE LAST -- --
<br />2. SEX
<br />24. AUTOPSY
<br />1 DATE OF DEATH /Month. Day. Yee0
<br />Orin Ed ar
<br />Beeder
<br />Male
<br />December 8, 1989
<br />4. CITY AND STATE OF BIRTH (d not in U.S.A., name countryl
<br />Yea ❑ No ❑
<br />Sa. AGE - Last Birthday
<br />(Specify Yes gJvo
<br />(Spec
<br />1V0 l
<br />28a. ACCIDENT, SUICIDE, HOMICIDE, UNDET.,
<br />OR PENDING INVESTIGATION (specdy)
<br />126b. DATE OF INJURY (Mo.,Dey, Yr.)
<br />6. DATE OF BIRTH (Month, Day. Yearl
<br />Sb. N08. GAYS
<br />Sc. HOURSI
<br />MINS.
<br />-
<br />(Yrs,)
<br />260. INJURY AT WORK
<br />( North Platte, Nebraska
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />57
<br />office building, etc. (Specify)
<br />October 15, 1932
<br />Y: AOGAL SECURITY NUM
<br />aa. P GF bF
<br />Tn
<br />HOSPITAL AO�Inpatiem ❑ ER: Outpatient ❑ DOA
<br />506 30 9014
<br />OTHER n N urw*Han. o I4i- "1 ❑ Older fspeeifyl
<br />8b. FACILITY - Name (if na inpitufion, give street and numberl
<br />Sc. CITY, TOWN OR LOCATION DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />28c. PRONOUNCED DEAD (Mo., Day, Yr)
<br />28d. PRONOUNCED DEAD (Hour)
<br />(Specify Yes or Nol
<br />I
<br />I
<br />Bryan Memorial Hospital
<br />10:45 A m
<br />Lincoln
<br />Yes
<br />Lancaster
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />27d. To the best of my kn death occurred anN time, dam and place and due to the
<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 Islan +l•
<br />1605 N Lafayette 68803
<br />ecif, Yes of
<br />(Yes NO)
<br />10. RACE - (e.g.. While, Black, American Indian,
<br />11. ANCESTRY (s.q.,ftalian, Mexican, German, slo.)
<br />12. (t4RRIED,NEVER MARRIED,
<br />13.
<br />NAME OF SPOUSE (ff wife, gwe maiden name)
<br />etc.) (specify)
<br />(Specify)
<br />f
<br />�MryryC�SppWED, DIVORCED (Spetdyl
<br />32a. - -
<br />White
<br />American
<br />Married
<br />Bernice Franssen
<br />14a. USUAL OCCUPATION (Give Idnd of work done during most
<br />of sorting fife even d rehrsd)
<br />3
<br />lab. KIND OF BUSINESS INDUSTRY
<br />Elementary
<br />r
<br />b bo
<br />or Secondary (0.12) Collage (1 -4 or 5•)
<br />1
<br />Brick La er
<br />Buildin Construction
<br />12
<br />16. FATHER -NAME FIRST MIDDLE
<br />UST
<br />17. MOTHER - MAIDEN NAME
<br />FIRST MIDDLE LAST
<br />Charles
<br />Beeder
<br />Hazel S ink
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19. INFORMANT - NAME - MAILING ADDRESS
<br />(STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIPL
<br />(Yes, no, or unk.) (it Yes, give war and dates d services)
<br />I
<br />8 O 03
<br />6 0
<br />I I
<br />Bernice Beeder, 1605
<br />N Lafa ette Grand Island, NE
<br />20a. BURIAL, Cremation,Removal,
<br />20b. DATE
<br />2Dc. CEMETERY OR CREMATORY - NAME
<br />20d. LOCATION CITY OR TOWN STATE
<br />Donation
<br />-
<br />Burial
<br />Dec 12, 1989
<br />Westlawn Memorial Park
<br />Grand Island, Nebraska
<br />21. EMBALMER 6 LICfX.SE NO. -L (gyp 8
<br />22. FUNERAL HOME. NAME AND ADDRESS
<br />(STREET OR R.F.D. NO., CITY OR TOWN, STAIgEPi 6880 1
<br />LIVINGSTON- SONDERMANN F.H.,
<br />505 W KOENIG, GRAND ISLAM
<br />23 PART IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (c))
<br />I Interval between onset and death
<br />',u Brainstem hemorrhage
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />�
<br />,
<br />IN
<br />I Interval between onset and death
<br />I
<br />I
<br />OTHER Srn_.BFiOANT CONDITIONS - Conditions contributing to death but not related
<br />P^Hr
<br />PART 111 IF FEMALE. WAS THERE A
<br />24. AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />ff
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />(Specify Yes or No)
<br />EXAMINER OR CORONER?
<br />diabetes mellitus
<br />Yea ❑ No ❑
<br />No
<br />(Specify Yes gJvo
<br />(Spec
<br />1V0 l
<br />28a. ACCIDENT, SUICIDE, HOMICIDE, UNDET.,
<br />OR PENDING INVESTIGATION (specdy)
<br />126b. DATE OF INJURY (Mo.,Dey, Yr.)
<br />26c. HOUR OF INJURY
<br />_
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />No
<br />No
<br />MI
<br />260. INJURY AT WORK
<br />281. PUCE OF INJURY - At home, farm, street, factory,
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />(Specify Yes or Nol
<br />No
<br />office building, etc. (Specify)
<br />27a. DATE OF 'DEATH (MO.. Day, Yr.)
<br />28a. DATE SIGNED (Mo., Day, Yr.)
<br />2gp, TIME OF DEATH
<br />a
<br />December 8 1989
<br />27b. DATE SIGNED (Mo.,, Day, Yr.)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (Mo., Day, Yr)
<br />28d. PRONOUNCED DEAD (Hour)
<br />10:45 A m
<br />3
<br />'o �
<br />27d. To the best of my kn death occurred anN time, dam and place and due to the
<br />28e. On the basis dexaminabon:andjw mvestigation,.m my opinion death occurred at
<br />causes) stated.
<br />/N .,'
<br />a
<br />the dple,�slp and Place entl due to itle ehusesl staled.
<br />St nature and Title 47 r
<br />nature a -
<br />28a. DID TOBACCO USE CONTRI UTE TOT H?
<br />30a. HAS OMAN OR TISBUE DONATION BEEN CON$ID 6L?
<br />30b. WAS CONSENT GRANTED ?' _
<br />❑ YES XNO ❑ UNKNOWN
<br />'STYES `.. �IgO
<br />V
<br />n/a El YES ALI NO
<br />31. NAME AND ADDRESS OF CERTIREH (PHYSICAN, CORON PHYSICAN OR COUNTY ATTORNEY) (Type or Print)
<br />Benjamin R. Gelber, M.D. 2221.So. 17.th Suite 310, 4iftcoln, NE 68502
<br />32a. - -
<br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr)
<br />7TRAR
<br />M
<br />DEC 2 0 1989
<br />1ig-
<br />l
<br />
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