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-- 99 109383
<br />WHEN THIS COPY CARMS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES (�
<br />SYSTEM, R CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECQWQ WFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, WTAL STATISTICS JECn- 0114,1164TH IS ,
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE 200105007
<br />APR 71998 A/YLEiri& Coopot
<br />ASS9fANT 3FIiI'LJWP1STRAR
<br />LINCOLN, NEBRASKA HEALTH AND 6MAN -JERDIM -SVM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SE_ VICES FWANCE.AND- SUPPWT
<br />VITAL STATISTICS =
<br />CERTIFICATE OF DEATH
<br />1 DECEDENT - NAME FIRST MIDDLE LAST
<br />2 SEX "= --
<br />M
<br />T'
<br />Charles Fredrick Lange
<br />Male
<br />March 21, 1998
<br />•. CITY AND STATE OF BIRTH /If non h U S.A.. name counMl
<br />Sa. AGE - Last Birthday
<br />r"t
<br />UNDER I DAY
<br />6. DATE OF BIRTH /MOndr. Day. Year)
<br />5b. MOS. DAYS
<br />rn
<br />Wood River, Nebraska
<br />(Yrs.)
<br />54
<br />May 2, 1943
<br />7. SOCIAL SECURTIY NUMBER
<br />Ba. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER ® Nursing Home
<br />z
<br />_
<br />9b. FACILITY - Name (11 not insetiidn, give sheet and numbw)
<br />Lakeview Nursing Center
<br />❑ DOA ❑ Other(Specdyi
<br />!c. CITY. TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />;G'
<br />=
<br />M
<br />D
<br />CA
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />CS
<br />Cn
<br />C:)
<br />CD
<br />Grand Island
<br />2515 W. John 68803
<br />Yes ® No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY leg- Italian. Mexican. German, etc) �
<br />-3
<br />=1
<br />N
<br />C2
<br />NEVER DIVORCED
<br />Colleen Willey
<br />27D. DATE SIGNED /MO. Day Yr./
<br />27c TIME OF DEATH
<br />a
<br />28c PRONOUNCED DEAD into.. Day, Y0
<br />-4 Ost
<br />p
<br />:00
<br />ISpecily, only highest grade canpbled)
<br />Elementary or Secondary (0 -12) Canoga 114 or 5.1
<br />Of working life, even drettred) V V
<br />Salesman
<br />Car Dealership
<br />-< O
<br />[16, ATHER - NAME FIRST MIDDLE LAST r7 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />William NMN Lane Frieda Ann Baeder
<br />AS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />es. na. , unk.l 'J yes. give war and dates 01 services)
<br />No National Guard 1963 -1969
<br />Colleen Lane _
<br />19b INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />2515 W. John, Grand Island, Ne. 68803
<br />8 LICENSE NO
<br />21a. METHOD OF DISPOSITION
<br />211b. DATE 21c. CEMETERY OR CREMATORY NAME
<br />=ATURE
<br />R I /43
<br />Burial ❑Removal
<br />Mar. 24, 19981' Westlawn Memorial Park
<br />22a FUNERAL HOME - NAME
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />'
<br />Livingston- Sondermann F.H.
<br />11 Cremation El Donauor
<br />� Grand Island, Nebraska
<br />226. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Ne. 68803 -4050
<br />21 NAMEOIAT CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR Ial. Ib). AND Ic)) Interval between onset and dean,
<br />PART /
<br />1
<br />lal
<br />Cf)
<br />GJ
<br />U)
<br />O
<br />cc
<br />?j
<br />D
<br />O
<br />d11P
<br />Lot Two (2) In Block Eight (8), In Bonnie Brae Addition to the City of Grand Island,
<br />Hall County,
<br />Nebraska
<br />-- 99 109383
<br />WHEN THIS COPY CARMS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES (�
<br />SYSTEM, R CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECQWQ WFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, WTAL STATISTICS JECn- 0114,1164TH IS ,
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE 200105007
<br />APR 71998 A/YLEiri& Coopot
<br />ASS9fANT 3FIiI'LJWP1STRAR
<br />LINCOLN, NEBRASKA HEALTH AND 6MAN -JERDIM -SVM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SE_ VICES FWANCE.AND- SUPPWT
<br />VITAL STATISTICS =
<br />CERTIFICATE OF DEATH
<br />1 DECEDENT - NAME FIRST MIDDLE LAST
<br />2 SEX "= --
<br />3,:pATi_QF�EATH (Month Day Year)
<br />Charles Fredrick Lange
<br />Male
<br />March 21, 1998
<br />•. CITY AND STATE OF BIRTH /If non h U S.A.. name counMl
<br />Sa. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER I DAY
<br />6. DATE OF BIRTH /MOndr. Day. Year)
<br />5b. MOS. DAYS
<br />5c. HOURS MINS.
<br />Wood River, Nebraska
<br />(Yrs.)
<br />54
<br />May 2, 1943
<br />7. SOCIAL SECURTIY NUMBER
<br />Ba. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER ® Nursing Home
<br />505 -52 -3635
<br />❑ ER Outpatient ❑ Residence
<br />9b. FACILITY - Name (11 not insetiidn, give sheet and numbw)
<br />Lakeview Nursing Center
<br />❑ DOA ❑ Other(Specdyi
<br />!c. CITY. TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />' Grand Island Yes F N 1:1
<br />I Hal l _
<br />9a RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d STREET AND NUMBER !Including Zip Cade)
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2515 W. John 68803
<br />Yes ® No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY leg- Italian. Mexican. German, etc) �
<br />12. © MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (a mien. give maidlen name/
<br />mt.)ISoecilyl
<br />(Specify)
<br />I
<br />NEVER DIVORCED
<br />Colleen Willey
<br />27D. DATE SIGNED /MO. Day Yr./
<br />27c TIME OF DEATH
<br />a
<br />28c PRONOUNCED DEAD into.. Day, Y0
<br />USUAL OCCUPATION /Give kindof won done during most n
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION
<br />ISpecily, only highest grade canpbled)
<br />Elementary or Secondary (0 -12) Canoga 114 or 5.1
<br />Of working life, even drettred) V V
<br />Salesman
<br />Car Dealership
<br />1 Year
<br />[16, ATHER - NAME FIRST MIDDLE LAST r7 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />William NMN Lane Frieda Ann Baeder
<br />AS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />es. na. , unk.l 'J yes. give war and dates 01 services)
<br />No National Guard 1963 -1969
<br />Colleen Lane _
<br />19b INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />2515 W. John, Grand Island, Ne. 68803
<br />8 LICENSE NO
<br />21a. METHOD OF DISPOSITION
<br />211b. DATE 21c. CEMETERY OR CREMATORY NAME
<br />=ATURE
<br />R I /43
<br />Burial ❑Removal
<br />Mar. 24, 19981' Westlawn Memorial Park
<br />22a FUNERAL HOME - NAME
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />'
<br />Livingston- Sondermann F.H.
<br />11 Cremation El Donauor
<br />� Grand Island, Nebraska
<br />226. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Ne. 68803 -4050
<br />21 NAMEOIAT CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR Ial. Ib). AND Ic)) Interval between onset and dean,
<br />PART /
<br />1
<br />lal
<br />UVt I U, U.C. Nl.I.WWCVU-Vr
<br />Ibf
<br />DUE TO, OR AS A CONSEOUENCE OF
<br />Interval between OT1sel and dear,
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />25 WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />T
<br />iEXAMINER OR CORONER
<br />B
<br />(Ages 10 -54) Yes -
<br />Vas No
<br />X Yes No
<br />26a
<br />26b. DATE OF INJURY /Mo.. Day. Yr.]
<br />26c HOUR OF INJURY
<br />26d. DESCRIBE HOW ' NJURY OCCURRED
<br />Accident F-1 U,oelen --d
<br />M
<br />❑ Suwde n Pending
<br />26e. IN rURY AT WORK
<br />261, oPe buQilEirINJURY
<br />1L.qq - AT home - farm. wrest. factory
<br />26g. LOCATION STREET OR P.F.D. NO. CITY OR TOWN STATE
<br />Homicide investigation
<br />yes ❑ No ❑
<br />27a DATE OF DEATH (Mo Day Yr.)
<br />28a DATE SIGNED !Me Day. Yr I
<br />281b TIME OF DEATH
<br />a
<br />X March 21, 1998
<br />27D. DATE SIGNED /MO. Day Yr./
<br />27c TIME OF DEATH
<br />a
<br />28c PRONOUNCED DEAD into.. Day, Y0
<br />28d. PRONOUNCED DEAD (Noun
<br />a
<br />March 24 998
<br />Y'3:25 AM
<br />>
<br />�
<br />s
<br />M
<br />'W
<br />M
<br />27d To the best of my ed e. idea occurred at the li ate and place and due to the
<br />d To
<br />28e. On the bans of examination and or investigation, in my opinion death occurred at
<br />° °
<br />slated.
<br />0 5
<br />the time. date and place and due to the cause(s) stated.
<br />(Sign ature and Title!
<br />ISi nature and Ttle
<br />29, DID TOBACCO USE CON T O THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION BEE CONSIDERED?
<br />30.b WAS CONSENT GRAN7E11
<br />X, ❑ YES %O ❑ UNKNOWN
<br />❑ YES NO
<br />❑ YES XNO
<br />31. NAME AND ADDRESS O CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type or Intl
<br />X Dr. John A. Yagoner, Me 800 N. Alpha, Grand Island, Ne. 68803
<br />321. REGISTRAR
<br />�w�af ;WM"
<br />32b. DATE FILED BY jrR„/�Da����
<br />K ��
<br />
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