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<br />WHEN THIS COPY CAMWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REC
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST$S',
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />CIL N
<br />NEBRASKA O O O �' HEALTH AS3 /3' iWf
<br />AND HWA#
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<br />STATE
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<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES- fMii�iC Np SUP iRT
<br />VITAL STATISTICS
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<br />t DECEDENT -NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3. DATE OF DEATH /Moron. Day. ✓earl
<br />Lester Donald Behring
<br />Male
<br />June 22, 2001
<br />D
<br />5a. AGE - Last Birthday
<br />UNDER 1 DA Y
<br />6. DATE OF BIRTH /Monts. Day Year
<br />T
<br />(Y's1 73
<br />�UNDER
<br />S
<br />S
<br />December 20, 1927
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />507 -34 -6902
<br />H- OSPIT- AL. inpatient OTHER ❑ Nursing Hom
<br />❑ ER Outpatient ❑ Residence
<br />Bb. FACILITY - Name Mnor rnstaulioo, give skee/ and number)
<br />M
<br />cn
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />Yes © No ❑
<br />Hall
<br />I
<br />9a. RESIDENCE - STATE
<br />COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d STREET AND NUMBER pncluding Lp Code!
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />1915
<br />Hall
<br />Grand Island
<br />4231 W. Capital Ave.
<br />Yea ® Nd ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (a g.. Italian. Mexican. German, etc'
<br />t 2. R MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE rif wils . give maiden name/
<br />ai(Sbeci011 White
<br />Specify) American
<br />NEVER DIVORCED
<br />Mary F. Vodehnal
<br />14a. USUAL OCCUPATION /Give kindof work dare during most t
<br />4b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade compel la0(
<br />of waking Ills, even d reload!
<br />Contractor/Carpenter
<br />o
<br />M
<br />(A
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Louis Behring I
<br />Rosie Goehrinjz
<br />I& WAS DECEASED EVER IN U.S. ARMED FORCES'
<br />1ga. INFORMANT - NAME
<br />(Yes. no or unk) (11 yes. give war and dates of services)
<br />I
<br />No I
<br />Mary Behrin
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />4231 W. Ca tial Ave. Grand Island NE. 68803
<br />20.E LMER - SIGNATURE 8 LICENSE NO. (�
<br />21a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />�4
<br />x
<br />June 26, 2001
<br />Grand Island Cemetery
<br />e. FUNERAL WME - NAME
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes
<br />❑c'emat'on ❑Donarn,
<br />Grand Island, NE.
<br />c
<br />1123 West Second, Grand Island, NE. 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la). (b). AND (c)I Interval between onset and death
<br />PART
<br />I Ial Respiratory Arrest
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />COPD
<br />(bl
<br />DUE TO. OR AS A CONSEOUENCE OF Interval between onset and team
<br />(cl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />II
<br />IN THE PAST 3 MONTHS
<br />EXAMINER OR CORONER'
<br />(Ages
<br />10 -54( Yes No
<br />Vey No
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY IMO.. Day Yc/
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Ac Undetermined
<br />M
<br />Su,c de Pending
<br />INJURY farm. street. factory
<br />26e INJURY AT WORK 26f oNice
<br />26g. LOCATION STREET OR R F.0 NO CITY OR TOWN STATE
<br />Homicide Investigation
<br />buCE
<br />lSPeomI
<br />Yes ❑ No ❑
<br />27a. DATE OF DEATH /Mo.. Day. Yr)
<br />28a. DATE SIGNED (Mo.. Day. Yr)
<br />281, TIME OF DEATH
<br />�5
<br />June 22, 2001
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<br />27b DATE SIGNED /Mo.. Day. Yrl
<br />27c TIME OF DEATH
<br />28c. PRONOUNCED DEAD IMo Day, Yr.)
<br />28d. PRONOUNCED DEAD /Hour)
<br />June 22, 2001
<br />8:10 AM
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<br />27d to the best of my knowledge ath our a at the time. date a place and due to the
<br />28e. On the basis of examination and or investigation, in my opinion death occurred at
<br />e
<br />2 � .8
<br />causelsl stated. (
<br />°
<br />the time, date and place and due to the causes) stated
<br />(Signature and Title ► >
<br />(Si tune antl Title
<br />29. OID T USE CONTRIBUT E D 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN SIDERED' 30.b
<br />WAS CONSENT GRANTED'
<br />YES ❑ NO UNKNOWN
<br />❑ VES NO
<br />WHEN THIS COPY CAMWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REC
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST$S',
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />CIL N
<br />NEBRASKA O O O �' HEALTH AS3 /3' iWf
<br />AND HWA#
<br />O
<br />F-a
<br />-�J
<br />STATE
<br />a
<br />Q '*7
<br />X rri
<br />P
<br />GI'�J
<br />F1
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES- fMii�iC Np SUP iRT
<br />VITAL STATISTICS
<br />CF.RTTFTCATF OF T)FATTT
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<br />n7nd,�
<br />t DECEDENT -NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3. DATE OF DEATH /Moron. Day. ✓earl
<br />Lester Donald Behring
<br />Male
<br />June 22, 2001
<br />4. CITY AND STATE OF BIRTH 11lrraf k1 USA.. name couneyl
<br />5a. AGE - Last Birthday
<br />UNDER 1 DA Y
<br />6. DATE OF BIRTH /Monts. Day Year
<br />Grand Island, Nebraska
<br />(Y's1 73
<br />�UNDER
<br />S
<br />Sc HOURS MINS
<br />December 20, 1927
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />507 -34 -6902
<br />H- OSPIT- AL. inpatient OTHER ❑ Nursing Hom
<br />❑ ER Outpatient ❑ Residence
<br />Bb. FACILITY - Name Mnor rnstaulioo, give skee/ and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other /Spec -tv
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />Yes © No ❑
<br />Hall
<br />I
<br />9a. RESIDENCE - STATE
<br />COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d STREET AND NUMBER pncluding Lp Code!
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />1915
<br />Hall
<br />Grand Island
<br />4231 W. Capital Ave.
<br />Yea ® Nd ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (a g.. Italian. Mexican. German, etc'
<br />t 2. R MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE rif wils . give maiden name/
<br />ai(Sbeci011 White
<br />Specify) American
<br />NEVER DIVORCED
<br />Mary F. Vodehnal
<br />14a. USUAL OCCUPATION /Give kindof work dare during most t
<br />4b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade compel la0(
<br />of waking Ills, even d reload!
<br />Contractor/Carpenter
<br />Construction
<br />Elementary or Secondary 10121 College 11.40 5•I
<br />1 L
<br />16. FATHER -NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Louis Behring I
<br />Rosie Goehrinjz
<br />I& WAS DECEASED EVER IN U.S. ARMED FORCES'
<br />1ga. INFORMANT - NAME
<br />(Yes. no or unk) (11 yes. give war and dates of services)
<br />I
<br />No I
<br />Mary Behrin
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />4231 W. Ca tial Ave. Grand Island NE. 68803
<br />20.E LMER - SIGNATURE 8 LICENSE NO. (�
<br />21a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />�4
<br />r �Burial El Removal
<br />June 26, 2001
<br />Grand Island Cemetery
<br />e. FUNERAL WME - NAME
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes
<br />❑c'emat'on ❑Donarn,
<br />Grand Island, NE.
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D NO CITY OR TOWN. STATE. ZIP(
<br />1123 West Second, Grand Island, NE. 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la). (b). AND (c)I Interval between onset and death
<br />PART
<br />I Ial Respiratory Arrest
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />COPD
<br />(bl
<br />DUE TO. OR AS A CONSEOUENCE OF Interval between onset and team
<br />(cl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />II
<br />IN THE PAST 3 MONTHS
<br />EXAMINER OR CORONER'
<br />(Ages
<br />10 -54( Yes No
<br />Vey No
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY IMO.. Day Yc/
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Ac Undetermined
<br />M
<br />Su,c de Pending
<br />INJURY farm. street. factory
<br />26e INJURY AT WORK 26f oNice
<br />26g. LOCATION STREET OR R F.0 NO CITY OR TOWN STATE
<br />Homicide Investigation
<br />buCE
<br />lSPeomI
<br />Yes ❑ No ❑
<br />27a. DATE OF DEATH /Mo.. Day. Yr)
<br />28a. DATE SIGNED (Mo.. Day. Yr)
<br />281, TIME OF DEATH
<br />�5
<br />June 22, 2001
<br />_ w
<br />M
<br />N
<br />$ i C >
<br />27b DATE SIGNED /Mo.. Day. Yrl
<br />27c TIME OF DEATH
<br />28c. PRONOUNCED DEAD IMo Day, Yr.)
<br />28d. PRONOUNCED DEAD /Hour)
<br />June 22, 2001
<br />8:10 AM
<br />M
<br />g
<br />27d to the best of my knowledge ath our a at the time. date a place and due to the
<br />28e. On the basis of examination and or investigation, in my opinion death occurred at
<br />e
<br />2 � .8
<br />causelsl stated. (
<br />°
<br />the time, date and place and due to the causes) stated
<br />(Signature and Title ► >
<br />(Si tune antl Title
<br />29. OID T USE CONTRIBUT E D 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN SIDERED' 30.b
<br />WAS CONSENT GRANTED'
<br />YES ❑ NO UNKNOWN
<br />❑ VES NO
<br />❑ YES ' O
<br />31 NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) IType a Print!
<br />W. J. Lawton M.D. 2444 W. Faidley Ave., Grand Island, NE. 68803
<br />32a. REGISTRAR /�
<br />32b. DATE FILED BY REGISTRAR /Mo.. Day. rtj
<br />,,,.,Gn /_ �-. I
<br />.111N Z 8 2nni
<br />
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