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<br />WHEN THIS COPYCARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND - ERIIIGES
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REP W 09)%E W
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<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM VITAL STATISTICS E 1
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />JUN 2 s 2001 200106649 _. A 06
<br />ASSISTANT STA*rE 140GIST[t R
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICE$ F (tJANCFrAND:SF3PPORT
<br />VITAL STATISTICS - -- 01 06822
<br />CERTIFICATE OF DEATH
<br />I UL(:EDENT -NAME FIRST MIDDLE LAST 2 SEX - 3 DATE OF DEATH [Montt, D,rl Year,
<br />Donald F. Ber holz Male'
<br />g June 20, 2001 _
<br />4. CITY AND STATE OF BIRTH (l/not m US.A.. name country) 5a AGE,- Last Birthday UNDER 1 DAY 6. DATE OF BIRTH (Month. Day Year,
<br />IYrs [,,tUNDERIYEAR
<br />DAYS 5c. HOURS, MIN$
<br />Grand Island, Nebraska 75 February 2, 1926
<br />7 SOCIAL SECURTIV NUMBER Ba. PLACE OF DEATH _ --' --
<br />5 0 6- 2 0 - 3 6 5 9 HOSPITAL a Inpatient OTHER ❑ Nursing Home
<br />a - - -
<br />90 FACILITY - Name (a oolnstitution , give street and number) ❑ ER Outpatient ❑ Residence
<br />St. Francis Medical Center ❑ DOA ❑ Other (Specify,
<br />Bc. CITY TOWN OR LOCATION OF DEATH Bid INSIDE CITY LIMITS 8e COUNTY OF DEATH
<br />Grand Island Yes © No ❑ Hall
<br />9a. RESIDENCE - STATE 9b COUNTY 9c CITY. TOWN OR LOCATION - 90. STREET AND NUMBER (tnc udin9Zp Code) i ;, WSIDt CITY LIMA S
<br />Nebraska Hall Grand Island 2123 W. 10th 68803 Yes No
<br />10 RACE leg.. White. Black. American Indian. 11. ANCESTRY leg_ Italian. Mexican. German, etcl 12. FX-] MARRIED ❑ WIDOWED 13 NAME OF SPOUSE QI wile give maiden name)
<br />etc I (Soeclty) (Specfyy) NEVER
<br />White American MARRIED DIVORCED Erma Cornelius
<br />14a USUAL OCCUPATION (Give kind of work done during most 141 KIND OF BUSINESS INDUSTRY 15 EDUCATION ISpecaty only highest grade completedl
<br />of working life, even it retired) Elementary or Secondary (0 -121 College 1 4 o, 5 -I
<br />Car & Derrick Foreman Railroad 12
<br />16. FATHER -NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Richard Bergholz Minnie Schroeder
<br />18 WAS DECEASED EVER IN U.S. ARMED FORCES? WWII 191. INFORMANT -NAME -
<br />(Yes. no or uhk.) ilt yes. give war and dates of services)
<br />Yes June 1944 /March 1946 Erma Ber holz
<br />19b INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />2123 W. 10th St. Grand Island Nebraska 68803 _
<br />20 LMER -SIG E 8 LICENSE ) 21 a. METHOD OF DISPOSITION 21b. DATE - 21c CEMETERY OR CREMATORY NAME
<br />vl (� /� G) / 7/ X❑eenal Removal June 22 , 200 Westlawn Memorial Park
<br />2 NERAL HOME - NA E 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />All Faiths Funeral Home ❑cremal0n �D °na " °" Grand Island Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO_ CITY OR TOWN. STATE. ZIP) - - - --
<br />2929 S. Locust St, Grand Is nd Nebraska 68801
<br />23. IMMEDIATE C IENTE ONLY ONE A SE PER LINE FOR lal. (bl. AND (c)I Interval between onse d neam
<br />PART
<br />1 0
<br />(al I z
<br />DUE TO, O AS A CONSEOU CE OF -_
<br />e � � I Interval between onset a d eat
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<br />OT SIGNIFICANT NDITI - Conditions contriDuling eat t not relate RT III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFE D 70 MEDI
<br />PART EGNANCV IN THE PAST 3 MONTHS' EXAMINER OR CO ERA
<br />es 70 -54) Yes No Ves No Yes No
<br />26a 26b. DATE OF INJURY [Mo.. Day. Yr) 26c HOUR OF IN 26d. DESCRIBE HOW INJURY OCCURRED
<br />Accoont Undetermined \ M
<br />'C S-0, L] .ending '26, INJURYATWORK 26f PLACE OF INJURY- At home farm. ',(reel. tactory 26g LOCATION STRFFTORR.FD NO /;Iry OR TOWN S1ATF
<br />° ❑ ❑ office budding. etc (Specify) -
<br />Hom�cltle Investigation Yes[-] No
<br />27a DATE OF DEATH (MO.. Day. Yr) 28a DATE SIGNED (Mo. Day Yr 1 28b TIME OF DEATH
<br />June 20, 2001
<br />is
<br />27b DATE SIG D (MO.. D . Yr) 27c TIME OF DEATH i 28c PRONOUNCED DEAD IMO. Day. Yr.) 28d. PRONOUNCED DEAD (Hit M_
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<br />a 27d To the big of my know dge. deal occurred at the time. date and Dlac nd due to the ° Q ou 28e. On the basis of examination and or investigation, in my opinion death occurred at
<br />cause(s) staled. 1 \ice 1/ �11Xy /e �Y�V /,I1L o the time. dale and place and due to the cause(s) stated
<br />(Signature and Title) ► l_ - `�"' -- ` - 'T"'1 -� IS, the
<br />and Titlel ►
<br />29 DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED', 30.b WAS CONSENT GRANTED(
<br />11 YES NO 1-1 UNKNOWN ❑ YES X NO ❑ YES NG
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type a Print,
<br />William J. Liandis 24A4 W Faidl 68803
<br />32a REGISTRAR 32b. DATE FILED BY REGISTRAR (MO.. Day Yr.[
<br />t� JUN 2 5 2001
<br />THE EAST HALF (E1 /2) OF LOT SEVEN (7) AND ALL OF LOT SIX (6), BLOCK SEVEN
<br />(7), DILL AND HUSTON'S ADDITION TO THE CITY OF GRAND ISLAND, HALL
<br />ii IK(TV nil:DDACVA
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<br />�.,- -- r I
<br />OT SIGNIFICANT NDITI - Conditions contriDuling eat t not relate RT III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFE D 70 MEDI
<br />PART EGNANCV IN THE PAST 3 MONTHS' EXAMINER OR CO ERA
<br />es 70 -54) Yes No Ves No Yes No
<br />26a 26b. DATE OF INJURY [Mo.. Day. Yr) 26c HOUR OF IN 26d. DESCRIBE HOW INJURY OCCURRED
<br />Accoont Undetermined \ M
<br />'C S-0, L] .ending '26, INJURYATWORK 26f PLACE OF INJURY- At home farm. ',(reel. tactory 26g LOCATION STRFFTORR.FD NO /;Iry OR TOWN S1ATF
<br />° ❑ ❑ office budding. etc (Specify) -
<br />Hom�cltle Investigation Yes[-] No
<br />27a DATE OF DEATH (MO.. Day. Yr) 28a DATE SIGNED (Mo. Day Yr 1 28b TIME OF DEATH
<br />June 20, 2001
<br />is
<br />27b DATE SIG D (MO.. D . Yr) 27c TIME OF DEATH i 28c PRONOUNCED DEAD IMO. Day. Yr.) 28d. PRONOUNCED DEAD (Hit M_
<br />E
<br />goo V O` 02:05 a I _ M
<br />a 27d To the big of my know dge. deal occurred at the time. date and Dlac nd due to the ° Q ou 28e. On the basis of examination and or investigation, in my opinion death occurred at
<br />cause(s) staled. 1 \ice 1/ �11Xy /e �Y�V /,I1L o the time. dale and place and due to the cause(s) stated
<br />(Signature and Title) ► l_ - `�"' -- ` - 'T"'1 -� IS, the
<br />and Titlel ►
<br />29 DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED', 30.b WAS CONSENT GRANTED(
<br />11 YES NO 1-1 UNKNOWN ❑ YES X NO ❑ YES NG
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type a Print,
<br />William J. Liandis 24A4 W Faidl 68803
<br />32a REGISTRAR 32b. DATE FILED BY REGISTRAR (MO.. Day Yr.[
<br />t� JUN 2 5 2001
<br />THE EAST HALF (E1 /2) OF LOT SEVEN (7) AND ALL OF LOT SIX (6), BLOCK SEVEN
<br />(7), DILL AND HUSTON'S ADDITION TO THE CITY OF GRAND ISLAND, HALL
<br />ii IK(TV nil:DDACVA
<br />THE EAST HALF (E1 /2) OF LOT SEVEN (7) AND ALL OF LOT SIX (6), BLOCK SEVEN
<br />(7), DILL AND HUSTON'S ADDITION TO THE CITY OF GRAND ISLAND, HALL
<br />ii IK(TV nil:DDACVA
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