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ED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />IS OF THE ORIGINAL RECORD ON F�1� SI
<br />W14EN THIS COPY C14RRIES THE � VITAL STATISTICS SECTION.
<br />SYSTEM+ IT CERTIFIES TME AND HUMAN SERVICES SYSTEM. + /J��
<br />HEALTH dl 6o
<br />THE NEBRASKA '"ANNLEY S. COOPER
<br />•
<br />THE GAL DEPOSITORY FOR VITAL RECORDS. Q
<br />GATE OF ISSUANCE
<br />200 �. 0 6 5 9 ASSISTANT STA SGSyS�TEM
<br />HEALTH AND HUMAN SERVI
<br />DEC7 2000 SERVICES FINANCE ANp SUPPORT
<br />NEBRASKA TH ANp HUMAN _
<br />LINCOLN. DEPARTMENT ZALAL STATISTICS
<br />STATE OF1�BRpSKA-
<br />rn D,ry Yean
<br />OF DEATH 3 DAIf OF OEATH 27 ! 2000
<br />CERTIFICATE ;El< November
<br />LAST MIDDLE Female In pay Year)
<br />FIRST Berger I DAY 6 DATE OF B,RIH iAa^ 1957
<br />Ann UNDER 1 YEAR UNDER
<br />1 OF D NAME Sharon "c HOURS MINS January 8 !
<br />Sa AGE Last &nndar PAYS
<br />Sp MOS '
<br />A namecotintrYl Ins' 43
<br />0 CITY AND STATE OF BIR1H in ° p 5 Nebraska 9a PLACE OF DEATH ❑ N. -flit
<br />Island! a OTHER
<br />Inoananl
<br />Grand HOSPITAL Residence
<br />® fR Ou,oaeen, �-- - -
<br />7 SOCIAL SECURTIV NUMBER 7p76 � Dow
<br />505 .505-82-7076 -
<br />-82- nd nembe,, 0 UDA
<br />I9+,a msmuoon 9,ye sneer a TH
<br />80 f AGILITY - Name 1 (rent -et" y1, COUNIV (lF UEA
<br />is Medical 6o INS DE CITY LIMITS Hali
<br />St. Franc ® ❑
<br />YM NO 1 Ya
<br />AI,ON OF DEATH M, •,IREEr AND NUMBS Rd
<br />Bc (:IIY TOWNORLOC A110N Sa•o11e Park
<br />Grand Island I-11° t�WN DRL ` 4385 W "'l, 9n'e maw ^a —'
<br />gp COUNTY Island 19 NAME OF SPOUSE I
<br />�.--� STATE Grand MARRIED ❑WIDOWED
<br />9a 1,1 SIUENCE Hall ,2 ® Berger
<br />�
<br />Nebraska 1lahan. Me +¢an. Ge,man e,u UiVORCED Jallles I n �519ra0e compleleol
<br />Nebra it ANCESTRY ieq NEVER N IS "N' '9 Cdw 4u'
<br />1 + Amerlcan 'an American MARRI ,S lemeA IO ,0 ,21
<br />t0 RACE Ie9�Wnne 0ac ISPeuM
<br />INDUSTRY Elememary a— Seco^�a'v
<br />etc I ISoec'NI White 14b KIND OF BUSINESS l l MAIDEN SURNAME
<br />d11119 most MIDOIf.
<br />Newspaper FIRST Kuhn -
<br />N Ie eHd d
<br />14a USUAL
<br />,CCU PAT,O G,v work done wv,w a ••„•,,,,, i $ i n MIDDLE , 7 MOTHER
<br />Advert LAST Eva
<br />FIRST Hanner
<br />16 FATHER - NAME Clarence
<br />INFORMANT -NAME
<br />f.VER IN U S ARMED
<br />FORCES° James Berger
<br />18 WAS DECEASED �n Yes q'Ye war and dales of semcesl T ATE ZIPI —� -��-
<br />IVOt' r unK I R F ONO CITY OR TOWN S 68803 i RY NAMC
<br />Lv0" STREET OR NE . —
<br />MAILINGADDRESS , Grand Island! 21c CEMF" "TERN ORCREMA O Crema
<br />,gb INFORMANT Park Rd- 21b DATE Central Nebraska jtAti
<br />Stolley 21a METHOD OF DISPOSITION I 2000
<br />4385 W - Nov . 28 ! C,TV oR rowN
<br />❑Removal H CREMAI')RY LpCAT1UN
<br />20 EMBALMER SIGNATURE 6 LICENSE NO ❑ Bunal 21d CEMETERY O Gibbon! Nebraska -
<br />Not Embalmed X 0 NAME pdnal
<br />❑ Gemaon .�• --- -.
<br />22a FUNERAL HOME
<br />Butler -Geddes TATS ZIPI Ime,va, en
<br />Apf el- ISTREET OR R F D NO CITY OR TOWNS 6n 801
<br />ADDHf SS Island LIE - U `
<br />Grand ! R al .bl AND Icli
<br />226 FUNERAL HOME Second, NE CAUSE PER LINE FO
<br />11 'L3 West IENIER ONLY ON' Inlr,vai nnlwn^n ons I
<br />IMMEDIAT C
<br />29 PART ,�/� C) Y\ C* i ,_ ��Inlw•nI te,lw,n,n o ' I,
<br />I _ _
<br />DUL TO.OR AS A (;ONSEO !�
<br />25 WAS CASE OR REFERRED
<br />CORONE P
<br />X61 24 AUTOPSY E %AMINER OR CO
<br />R AS A CONSEQUENCE OF THERE A No
<br />,)"I IO O PART 111 IF FEMALE WAS Yes
<br />PREGNANCY IN THE PAST 1 MONTHS Nu
<br />oea,n but rKA related NO Yes
<br />(cl ITIDN$ CpldNons COmrlbll11nq 101be IA<Ms 105A1 Yes
<br />26d DESCRIBE HOW INJURY OCCURRED
<br />OTHER SIGNIFICANT CONO
<br />PART 26c HOUR Of INJURY OR TOWN
<br />d A4p Day Yr) CttvO
<br />26b DATE OF INJURY ! STREET OR R' D NO
<br />M 2b9 LOCATION
<br />26a . At nM'e larm s,,.el laclOrY
<br />r-, pnnelerm�^eo �1 P ACE OF INJURY .280 TIME OF DEATH
<br />u AccIde01 INJURY AT WORK ��ce bu'1M^9 etc ISOec N)
<br />� y Pwna,M 21. ',ATE SIGNED
<br />MO Isar ' I
<br />Cl Su'c,0e ll Yes ❑ NO ❑
<br />❑ InvesNall 2Bd PRONOUNCED DEAD (i
<br />Da Yr) Md paY. Yr l
<br />ATE OF DEATH 1 Mp y E '� � 28c PRONOUNCED DEAD 27a D
<br />�. i 00 ocCUrrWi
<br />(� 27c TIME OF DEATH ,n „ n•ev'gal'o^ ,n mY a0'^'d'
<br />_ - A a,an
<br />atilt a sI su1M
<br />ATE SIGNED IMO ^- pay Yr 1 n M x 28- On'- bays d e.a ac cause)
<br />27b p C..Y ace ano one ,010e _
<br />^� ^� //�� ,Oa uma Gale and d
<br />�1 L ! .,,ALatgx °and Ouem _ - T�11e1► N7 GRANI ED'
<br />am c ned a1pl� - -� A f SIDE and 1 b W AS COHSE ❑ ® µ)
<br />« rlow-W I�) Jl 1 IDERED' YES
<br />27d 1 as0e TISSUE DONATION �81�E -ESN CONS I .
<br />' 70 a HAS ORGAN OR ❑ R j(I NO
<br />S nalwe and Tatel ► THE DEATH+ YES LLJ
<br />2g DID TOBACCO USE CONTRIBUTE TO _I A 1
<br />//�1 Ii /Ey�V/�,Q la ❑ IN ATTORNEY' Type a pNM1 / ^� /S ^d /,
<br />NO ��./J K Oay Yrl
<br />❑
<br />YES '
<br />72b DATE FILED BY REGISTRAR !
<br />Of IPHYSICUN .CORONERST'HVSIGUN OR COUN tN
<br />p NAME AND ADDRESS O M D. �
<br />Igoe Id G W'' LAG A.
<br />
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