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<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 DEPA4,XE�T_6,F°1yE�ALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL MP_OSITORY
<br />VITAL RECORDS. =�
<br />DATE OF ISSUANCE
<br />MAY 7 WO STANLEY S`� O-OPER, D11i *OR
<br />LINCOLN, NEBRASKA BUREAU OF Vi�Syji4tics
<br />20000-6733
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS _
<br />CERTIFICATE OF DEATH
<br />UCVCVCr'll - -t HHSl MIDDLE UST
<br />2 SEX
<br />3. DATE OF DEATH (Month. Day Year)
<br />Alfred Clarence Stolle
<br />Male
<br />Aril 24, 1990
<br />4. CITY AND STATE OF BIRTH /If holm US A. name country) 5a AGE ' Last Birthday R I YEAR 6. DATE OF BIRTH (Month. Day. Year)
<br />(Yra.) 50 MOS DAYS 5c. HOURS' WINS.
<br />St. Libor y, Nebraska 1 78 October 26, 1911
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />HOSPITAL: Inpatient - ER Outpatient ❑ DOA
<br />507 -16 -4925 OTHER ❑ NursingHOme ❑ ResMence a Other (Specify)
<br />8b. FACILITY -Nam (Il not insatunon. give street and number/
<br />Sc . CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />St. Francis Medical Center
<br />Grand Island
<br />(Specify Yes or No)
<br />Yes
<br />Hall
<br />9a. RESIDENCE -STATE 9D. COUNTY 9c. CITY. TOWN OR LOCATION 90. STREET AND NUMBER /Including Zip Cade/ 9e. INSIDE CITY LIMITS
<br />(Speay Yes or Nor
<br />Nebraska Hall Grand Island 1004 W. Howard 68803 Yes
<br />f0. RACE - le g_ White. Black, American Indian. 11. ANCESTRY (e.g.,ltalian. Mexican, German, etcl 12. MARRIED, NEVER MARRIED, 13. NAME OF SPOUSE (a -de. g,ve maden name)
<br />etc.) ISPW* ( Speciy/
<br />WIDOWED, DIVORCED /Specify)
<br />n
<br />m
<br />14b KIND OF BUSINESS INDUSTRY
<br />1
<br />of working )ik, even R reared)
<br />I I (.
<br />7a
<br />Elementary or Secondary .15 omokeledl
<br />(0 -12) College 11 -4 or 5.1
<br />Operator L
<br />Power Plant
<br />8th Grade
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />77. MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />William NMN Stolle
<br />Mar NMN Brabander
<br />18 WAS DECEASED EVER IN U.S. ARMED FORCES? �orravne 9. INFORMANT - NAME - MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)G 8803
<br />(Vas, no, or unk.) (If yes, give war and dates of services) V
<br />No - - - - -- Stolle 1004 N. Howard Grand Island Ne.
<br />202, BURIAL. Cremaeon,Removal, 20b. DATE 20c. CEMETERY OR CREMATORY - NAME 20d. LOCATION CITY OR TOWN STATE
<br />Donation
<br />Bu r,k61__'\ Dril 27 1990 Westlawn Memorial Park Grand Island Nebraska
<br />21. E MER - SIGN URE 8 E N0. 22. FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP) 68801
<br />Z 3y�
<br />Livin ston- Sondermann 505 W. Koenig, Grand Island, N.
<br />29. 1MMEOIA CAUSE (ENTER ONLY ONE CAUSER LINE FOR (a). (b), AND (ep I Interval between onset and death
<br />PART
<br />1
<br />e Vii.. 7 e� , '4T /'-i2 /� r -� �£ wl -
<br />�C
<br />1 Interval between onset and death
<br />DUE TO, OR AS A CONSEQUENCE OF: 7t FkF
<br />I
<br />DUE 70, OR AS A CONSEQUENCE OF 1 Interval between onset and death
<br />I
<br />I
<br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to death but not related
<br />PART III IF FEMALE, WAS THERE A
<br />ri
<br />L
<br />g
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />(Specify Yes or No)
<br />EXAMINER OR CORONER?
<br />Yes G No C
<br />A 1
<br />( Speci)y Yes or No)
<br />h
<br />DATE OF INJURY (MO.,Day. Yr)
<br />26c. HOUR OF INJURY
<br />DESCRIBE HOW INJURY CCURRED
<br />L
<br />r
<br />C- i>
<br />-;
<br />�,
<br />CD
<br />a.
<br />281. PUCE OF INJURY - At home, farm, street. factory,
<br />office building, etc. (SpecM
<br />2fig. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />27a. DATE OF DEATH (MO., Day, Yr.)
<br />28a. DATE SIGNED (Mo.. Day, Yr.)
<br />C:5
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<br />a
<br />a
<br />cti r-
<br />27D. DATE SIGNED (MO.. Day, Yr.)
<br />27t. TIME OF DEATH
<br />2 &. PRONOUNCED DEAD (MO., Day, Yr.l
<br />lu
<br />8YApril
<br />30.
<br />A: 12
<br />��€
<br />E
<br />o �
<br />27d. To tlb best of m kno
<br />y wbdge, deem occurred s hat
<br />co
<br />28e. On the basis of examination 2ntl1a investigation, in my o0inion death occurred at
<br />cause(s) stated.
<br />U `
<br />a
<br />ire bme, dab and place and due to the cause(s) stated
<br />I Lure and Title ►
<br />(Signal re and Title)
<br />26a. 010 TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30a. HAS ORGAN R TISSUE DONATION BEEN CONSIDERE01
<br />30b WAS CONSENT GRANTED?
<br />O YES O NO LINK OWN
<br />O YES NO
<br />❑ YES NO
<br />. NAME AND ADDRESS OF CERTIFIER (PHYSICAN, ORONER'S PHYSICAN OR COUNTY ATTORNEY) (Type or Pnnt/
<br />f•i r '"
<br />32. DAT ED BY REGIST MO.. Defy. Yo
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<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 DEPA4,XE�T_6,F°1yE�ALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL MP_OSITORY
<br />VITAL RECORDS. =�
<br />DATE OF ISSUANCE
<br />MAY 7 WO STANLEY S`� O-OPER, D11i *OR
<br />LINCOLN, NEBRASKA BUREAU OF Vi�Syji4tics
<br />20000-6733
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS _
<br />CERTIFICATE OF DEATH
<br />UCVCVCr'll - -t HHSl MIDDLE UST
<br />2 SEX
<br />3. DATE OF DEATH (Month. Day Year)
<br />Alfred Clarence Stolle
<br />Male
<br />Aril 24, 1990
<br />4. CITY AND STATE OF BIRTH /If holm US A. name country) 5a AGE ' Last Birthday R I YEAR 6. DATE OF BIRTH (Month. Day. Year)
<br />(Yra.) 50 MOS DAYS 5c. HOURS' WINS.
<br />St. Libor y, Nebraska 1 78 October 26, 1911
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />HOSPITAL: Inpatient - ER Outpatient ❑ DOA
<br />507 -16 -4925 OTHER ❑ NursingHOme ❑ ResMence a Other (Specify)
<br />8b. FACILITY -Nam (Il not insatunon. give street and number/
<br />Sc . CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />St. Francis Medical Center
<br />Grand Island
<br />(Specify Yes or No)
<br />Yes
<br />Hall
<br />9a. RESIDENCE -STATE 9D. COUNTY 9c. CITY. TOWN OR LOCATION 90. STREET AND NUMBER /Including Zip Cade/ 9e. INSIDE CITY LIMITS
<br />(Speay Yes or Nor
<br />Nebraska Hall Grand Island 1004 W. Howard 68803 Yes
<br />f0. RACE - le g_ White. Black, American Indian. 11. ANCESTRY (e.g.,ltalian. Mexican, German, etcl 12. MARRIED, NEVER MARRIED, 13. NAME OF SPOUSE (a -de. g,ve maden name)
<br />etc.) ISPW* ( Speciy/
<br />WIDOWED, DIVORCED /Specify)
<br />White American Married Lorra ne Wilhelmi
<br />146. USUAL OCCUPATION (Give kind of work done during most
<br />14b KIND OF BUSINESS INDUSTRY
<br />1
<br />of working )ik, even R reared)
<br />I I (.
<br />7a
<br />Elementary or Secondary .15 omokeledl
<br />(0 -12) College 11 -4 or 5.1
<br />Operator L
<br />Power Plant
<br />8th Grade
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />77. MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />William NMN Stolle
<br />Mar NMN Brabander
<br />18 WAS DECEASED EVER IN U.S. ARMED FORCES? �orravne 9. INFORMANT - NAME - MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)G 8803
<br />(Vas, no, or unk.) (If yes, give war and dates of services) V
<br />No - - - - -- Stolle 1004 N. Howard Grand Island Ne.
<br />202, BURIAL. Cremaeon,Removal, 20b. DATE 20c. CEMETERY OR CREMATORY - NAME 20d. LOCATION CITY OR TOWN STATE
<br />Donation
<br />Bu r,k61__'\ Dril 27 1990 Westlawn Memorial Park Grand Island Nebraska
<br />21. E MER - SIGN URE 8 E N0. 22. FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP) 68801
<br />Z 3y�
<br />Livin ston- Sondermann 505 W. Koenig, Grand Island, N.
<br />29. 1MMEOIA CAUSE (ENTER ONLY ONE CAUSER LINE FOR (a). (b), AND (ep I Interval between onset and death
<br />PART
<br />1
<br />e Vii.. 7 e� , '4T /'-i2 /� r -� �£ wl -
<br />�C
<br />1 Interval between onset and death
<br />DUE TO, OR AS A CONSEQUENCE OF: 7t FkF
<br />I
<br />DUE 70, OR AS A CONSEQUENCE OF 1 Interval between onset and death
<br />I
<br />I
<br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to death but not related
<br />PART III IF FEMALE, WAS THERE A
<br />24, AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />g
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />(Specify Yes or No)
<br />EXAMINER OR CORONER?
<br />Yes G No C
<br />A 1
<br />( Speci)y Yes or No)
<br />26a. ACCIDENT, SUICIDE, HOMICIDE, UNDET.,
<br />DATE OF INJURY (MO.,Day. Yr)
<br />26c. HOUR OF INJURY
<br />DESCRIBE HOW INJURY CCURRED
<br />OR PENDING INVESTIGATION (Spec iyl
<br />126b.
<br />126d.
<br />268. INJURY AT WORK
<br />(Speedy Yes or NO)
<br />281. PUCE OF INJURY - At home, farm, street. factory,
<br />office building, etc. (SpecM
<br />2fig. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />27a. DATE OF DEATH (MO., Day, Yr.)
<br />28a. DATE SIGNED (Mo.. Day, Yr.)
<br />28b. TIME OF DEATH
<br />April 24, 1990
<br />a
<br />a
<br />27D. DATE SIGNED (MO.. Day, Yr.)
<br />27t. TIME OF DEATH
<br />2 &. PRONOUNCED DEAD (MO., Day, Yr.l
<br />28d. PRONOUNCED DEAD (hour)
<br />8YApril
<br />30.
<br />A: 12
<br />��€
<br />E
<br />o �
<br />27d. To tlb best of m kno
<br />y wbdge, deem occurred s hat
<br />,dab and see arM due b the
<br />28e. On the basis of examination 2ntl1a investigation, in my o0inion death occurred at
<br />cause(s) stated.
<br />U `
<br />a
<br />ire bme, dab and place and due to the cause(s) stated
<br />I Lure and Title ►
<br />(Signal re and Title)
<br />26a. 010 TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30a. HAS ORGAN R TISSUE DONATION BEEN CONSIDERE01
<br />30b WAS CONSENT GRANTED?
<br />O YES O NO LINK OWN
<br />O YES NO
<br />❑ YES NO
<br />. NAME AND ADDRESS OF CERTIFIER (PHYSICAN, ORONER'S PHYSICAN OR COUNTY ATTORNEY) (Type or Pnnt/
<br />GISTRAR
<br />32. DAT ED BY REGIST MO.. Defy. Yo
<br />
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