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1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Son'a K 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.) 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Ord, Nebraska 5a AGE -Last Birthday (Yrs.) 52 5b. UNDER MOS. 1 YEAR DAYS 5c. UNDER HOURS 1 DAY MINS. es. 6. DATE OF BIRTH (Mo., Day, Yr.) January 23, 1954 7. SOCIAL SECURITY NUMBER 508 -78 -1928 Ba. PLACE OF DEATN HOSPITAL: ❑Inpatient ggEg ❑NursingHOmeILTC ❑Hospice Facility ❑ ER /Outpatient Decedent'sHome ❑ �, OOther(Specify) ` „'qR 8b. FACILITY -NAME (If not institution, give street and number) n `! 920 West Rosedale Road 8c. CITY OR TOWN OF DEATH (Include Zip Code) Doni•han 68:32 8d. COUNTY OF DEATH Hall ''?� 9a. RESIDENCE -STATE �� fl Nebraska 9b. COUMY ,- 9c. CITY OR TOWN l•• •a • �? 9d. STREET AND NUMBER 920 West Rosedale Road 9e. APT. NO 91. ZIP CODE 68832 9g. INSIDE CITY LIMITS ❑ YES Xl NQ =' 10a. MARITAL STATUS AT TIME OF DEATH .�,<;..,. � Married ❑Never Married z `a ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 106. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Mike Gartner 11. FATHER'S -NAME (First, - Middle, Last, Suffix) Mervin Winter 12. MOTHER'S -NAME (First, Middle, Maiden Surname) COn sta A CP Rrnwn 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. (Yes,no,orunk.) No �r 14a. INFORMANT -NAME Mike Gartner 14b. RELATIONSHIP TO DECEDENT Httghanr� A sll 15. METHOD OF DISPOSITION �'- Burial ❑Donation ❑ Cremation ❑ Entombment • ❑Removal ❑other(Specdy) 16a. EMBALMER- NATUR ia< 16b. LICENSE N0. 1279 18c. DATE (Mo., Day, Yr. ) 1 - 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Greenwood Cemetery Trumbull Nebraska 43'i 17a. FUNERALHOMENAMEANDMAILNGADDRESS (Street,CltyorTown,State) Livingston Butler Volland Funeral Home ■ '^' Y n {f 18. PART I. Enter the chain of events -- diseases, injuries, or complications- -that directly caused ,.; respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. IMMEDIATE CAU ?�.�. IMMEDIATE CAUSE (Final (a) '/t' /•((�//"((( ��(((��(((II��,�� Ad 1225 North Elm Avenue Hasten • s, Nebraska 1 * �i ?2 -b �y � ..... u...;. F- '..iy-t� the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE Enter only one cause on a line. Add additional lines 4 necessary. onset 17b.ZipCode 68901 INTERVAL to death disease or condition resulting DUE TO, OR AS A CO • QUENCE OF: In death) Sequentially list conditions, if (b) ((� t " leading I onset to death AtitierVi any, to the cause listed DUE TO, OR AS A CONSEQUENCE OF: onset to death ) a on line a. Enterthe UNDERLYING CAUSE (disease or Injury that initiated (c) the In death) events resulting LAST DUE TO, OR AS CONSEQUENCE OF onset to death (d) &d ► 0A . 18. PART II. OTHER SIGNIFICANT CONDITIONS -Co Cif contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTWED? ❑ YES U-40 20.IFFE1MALE: No t pregnant within past year ..: ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death �;. ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH Na Homicide ❑ Accident❑ Pending ❑ Suicide 0 Could not Investigation be determined -At home, farm, 21 b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger g ❑ Pedestrian ❑ Other S ec1f ( FY) 21c. WAS AN AUTOPSY PERFOR ? ❑ YES 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO site, etc. (Specify) m i• - 22a. DATE OF INJURY (Me., Day, Yr.) 22b. TIME OF INJURY m 22c. PLACE OF INJURY street, factory, office building, construction 22d. INJURY ATWORK? T .:. ❑ YES ❑ 140 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE Z a U fi - xk E Z ° Q .8"i 23a. DATE OF DEATH (Mo., Day, Yr.) December 24, 2006 Z ,.._z a t W t 1 - 41RJ E'+ _ 1) w -- G p o 1 24a. DATE SIGNED (Mo., Day, Yr.) 24b.TIME OF DEATH m 23b.D T N D (/J S1 (A1o y , Yr i , J /J /i 23c. TIME OF 3 A H m 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD m 23 . To the est of my k owledge, death occur ed at the time, date and place a e to the cause(s) stated. (Signature and Title) ♦ Ai / r I. /� /// 24e. On the basis of examination and /or investigation, In my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title ) • 25. DID TOBACCO USE CONT - TETOTHEDEATH? ❑ YES ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR E DONATION BEEN CONSIDERED? Y ❑ NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES 27. NAME, TITLE AND ADDRESS OFCERTIME PHYSICIAN, CORONER' HYSICIANORCOUNTYATTORNEY) (Type or Print) Paul C. Wibbels, 2 /15 North Kansas Avenue, Hastings, Nebraska 68901 28a. REGISTRAR'S SIGNATURE (0f42P0 A. 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) JAN 3 2007 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. , DATE OF ISSUANCE 201707007 JAN 0 4 2001 LINCOLN, NEBRASKA �6 TANLEY S. COOPER ASSISTANT STATE REGISTRAR HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPO � 6 34368 CERTIFICATE OF DEATH