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MIEN THIS COPY CARFUES THE RAISED SEAL OF THE NEBRASKA HEALTH AND , SERVICES rn K WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST C 'Is THE LEGAL DEPOSITORY FOR VITAL RECORDS = =' 5a. AGE - Last Birthday UNDER 1 YEAR T / M0� 0 O 6 CE 200006779 6. DATE OF BIRTH IMonrh. Dav Year) ASSISI REIi LINCOLN, NEBRASKA HEALTH AND HUMAAi . STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SER PHdANCE PORT Cr VITAL STATISTICS 506-44-0911 CFRTTFTCATF OF DEATH ❑ ER Outpatient ❑ Residence C m ❑ DOA ❑ Other (SpecM) &. CI. ' )WN- ORLQCATI OF DFAR _.... - ... - __,.,., _ , -.. Od.- INSIDE CITY LIMITS CD C) --i Yes ® No ❑ S D 915 COUNTY 9e. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER Ilncluding Zip Code) • INSIDE CITY LIMITS Nebraska r�` -, y Tv 11. ANCESTRY (e.9.. Italian. Mexican, German, etcl 12. ❑ MARRIED FX] WIDOWED p etc I ISoeatyl (Specity) DIVORCED Lucas L. Djernes (Dec White American MARRI M CA CA 15. EDUCATION (Specify only highest grade completed) z7 of working life, even if rebredl Homemaker -= —j rT! n Henry Ehrsam Armenta Good 18 WAS DECEASED EVER IN US. ARMED FORCES? 19a. INFORMANT - NAME (Yes. no, or unk.) (If yes. give war and dates of services) No - - - - - - - - Lucas Lyle Djernes 19b INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) 1885 "O" Road Central City, NE 68826 20 EMBALMER - SIGNATURE 8 LICENSE NO 2ta❑MBuHOD OF DISPOSITION 21c CEMETERY OR CREMATORY NAME � � oval March 2 , 20 O O Central City Cemetery 2AFUNEFiAL11-10ME � NAM 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Solt Funeral Home CD 1915 Hwy 14 Central City, NE 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO_ CITY OR TOWN. STATE. ZIP) 1507 17th Street Central City, NE 68826 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal (b). AND (cp Intervalgbetween onset and deam 121 PART 1 3 1)4 Y I lal A if DUE TO. OR AS A CONSEQUENCE OF I Interval between onset and death r o r , rn -_3 fv CA CD MIEN THIS COPY CARFUES THE RAISED SEAL OF THE NEBRASKA HEALTH AND , SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL K WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST C 'Is THE LEGAL DEPOSITORY FOR VITAL RECORDS = =' 5a. AGE - Last Birthday UNDER 1 YEAR T / M0� 0 O 6 CE 200006779 6. DATE OF BIRTH IMonrh. Dav Year) ASSISI REIi LINCOLN, NEBRASKA HEALTH AND HUMAAi . STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SER PHdANCE PORT Cr VITAL STATISTICS 506-44-0911 CFRTTFTCATF OF DEATH I DECEDENT-NA E FIRST MIDDLE LAST 2. SEX • 3 DATE OF DEATH (Month. Dav ✓earl Llewella Olga Djernes Female ebruary 26, 2000 4 CITY AND STATE OF BIRTH /lf not in USA. name courfol 5a. AGE - Last Birthday UNDER 1 YEAR UNDER i DAY 6. DATE OF BIRTH IMonrh. Dav Year) Central City, Nebraska Yrsl �� Sb MOS DAYS Sc HOURS MINS March 10, 1900 -- - -- 7 SOCIAL SECURITY NUMBER 8a PLACE OF DEATH 506-44-0911 H_OSPITA_L a Inpatient OTHER ❑ Nursing Home ❑ ER Outpatient ❑ Residence 8b. FACILITY - Name (n nof )nslltution, give street and numberl ❑ DOA ❑ Other (SpecM) &. CI. ' )WN- ORLQCATI OF DFAR _.... - ... - __,.,., _ , -.. Od.- INSIDE CITY LIMITS 8e COUNTY OF DEATH ' Central City Yes ® No ❑ Merrick 9a RESIDENCE - STATE 915 COUNTY 9e. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER Ilncluding Zip Code) • INSIDE CITY LIMITS Nebraska Merrick Central City 2720 17th Ave. Yes [N No 10 RACE - leg.. While . Black American Indian 11. ANCESTRY (e.9.. Italian. Mexican, German, etcl 12. ❑ MARRIED FX] WIDOWED 13 NAME OF SPOUSE !n wde give maiden name/ etc I ISoeatyl (Specity) DIVORCED Lucas L. Djernes (Dec White American MARRI J c>iz�o o v 14a USUAL OCCUPATION (Give kind of work done during most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) Elementary or Secondar 10 -12) College 1 4 of 1�Oth _ of working life, even if rebredl Homemaker Own Home 16 FATHER -NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Henry Ehrsam Armenta Good 18 WAS DECEASED EVER IN US. ARMED FORCES? 19a. INFORMANT - NAME (Yes. no, or unk.) (If yes. give war and dates of services) No - - - - - - - - Lucas Lyle Djernes 19b INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) 1885 "O" Road Central City, NE 68826 20 EMBALMER - SIGNATURE 8 LICENSE NO 2ta❑MBuHOD OF DISPOSITION 21c CEMETERY OR CREMATORY NAME � � oval March 2 , 20 O O Central City Cemetery 2AFUNEFiAL11-10ME � NAM 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Solt Funeral Home ❑Cremation ❑Donation 1915 Hwy 14 Central City, NE 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO_ CITY OR TOWN. STATE. ZIP) 1507 17th Street Central City, NE 68826 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal (b). AND (cp Intervalgbetween onset and deam 121 PART 1 3 1)4 Y I lal A if DUE TO. OR AS A CONSEQUENCE OF I Interval between onset and death 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 PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER' L Zrtk /Mf/LS (Ages 10 -541 Yes NO Yes NO Yes No , 26a 25b DATE OF INJURY (Mo. Day. Yr./ 26c. HOUR OF INJURY 26d. DESCRIBE HOW fNJURY OCCURRED Accident Undetermined M Suicide Pending 26e. INJURY AT WORK 261. PLACE OF INJURY - At home. farm, street lactory P 26g. LOCATION STREET OR R.F D. NO CITY OR TOWN STATE Homicide Investigation ❑ ❑ tce but d etc. lSpeciyl Yes No 27a. DATE OF DEATH (Mo.. Day. YrI 28a. DATE SIGNED (MO. Day Yr 1 2815 TIME OF DEATH = February 26 2000 o'i M 27b. DATE SIGNED (Mo. Day Yrl 27c. TIME OF DEATH 28c PRONOUNCED DEAD (Mo Day. Yrl 28d. PRONOUNCED DEAD !Hour) a DA 17:32 M J c>iz�o o v M B ° 27d. To the best of my know) death occurred at the time, da an dace and due to 28e. On the basis of examination and of investigation, In my opinion death occurred at causes) stated a e time, date and place and due to the cause(s) stated (Signature and Title IS nature and Title ► DID TOBACCO USE C0rIBFEj0 THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? 129 ❑ YES [Z N ❑ UNKNOWN YES ❑ NO ❑ YES ® NO 31 NAME AND ADDRESS lkCE FIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEVI /Type or Print' Jerome Gacke MD; 2510 18th Ave:- Central City, NE 68826 32a REGISTRAR A" DATE FILM ISTZ I`tt r q L) U06 N I cv fG. W co _M CD 2 d