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STATE OF NEBRASKA 9Ptaa9nt„,4, ate ;Z pV9NYa...., , `*wP/p /AdA +FYN' WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 5/29/2018 LINCOLN, NEBRASKA FIRST John CITY. AND STATE 09120TH atm' USA. .r*MAW; G rand Island, Nebraska `7' SOCIAL SECURTLYNUMWR 506 -40 -1976 66 FACILITY - NOme 1121. itoenig CITY T9Mfi1OR LQGATf09 OF DEATH Grand Island 9a RESIDENCE - STATE Nebraska EIO RA :;E -1e 9-:wM . 8la N-!nc6A WW et l,SdeORyi White 140 USUAL OCCUPATION ,Gne kraal a/.aany Me Omen 6,exetll Artist 16 FATHER 16 WAS DECEASED EVER IN US. ARMED FORCES' IYes ro auekl I Ilr M. gre ,HIP aro ayesd amloml MO • I t 92 MfOAIAiN SWUNG AOORCSS • 1_1 W A11 Faiths .Funeral Home ❑ own** 0 Delwvr Grand Island, Nebraska 226 FUNERAL HOME ADDRESS ISTREET OR RFD NO CITY OR TOWN STATE ZPI 2929 S. Locust St., Grand Island, Nebraska 68801 53 *MEDIATE. CAUSE (ENTER ONLY ONE CAUSE PER UNE FOR Ia1. 101. AND Icll PAR1 Cardiopulmonary arrest DUE : 10 DR AS ik:CDNSE0UENCE OF 29 31 OuE TO OR AS A CONSEOUEPIOE OF OT*kA 32a REGISTRAR SIAM OF NEBRASKA- DEPARTh TOf IEALTAND Ft1IMAN SERVICES FINANCE AND supra T AL 14544 STA> FIRST Herbert ryrINASealyk gN16.6aawnwr*•1 r 96 COUNTY i Hall 11. ANCESTRY le 9.. Wan. Woman. DermasNcl 12 ©MIMED 0 WIDOWED 13 NAME OE SPOUSE IN... 1F INrArrnlalyy Anerl ❑ 1 S 000544 : M NEVER ( DYORCED Karen Koenig ARRIED < ' 1 Wm Obey most 14c HIND OF BUS'*ESS INDuETRV 15 EDUCATION ISA...N a m r 0N, DOOM M+a*IA EMI.. a SICal6WY 10 Caaage 114 at 5 -t 2 1/2 MIDDLE F. 266 DATE OF MOW . 666 DM NYJ D At.<4.1'11 1.,X71011 J uoo6 : D Pe :. I e 6LA1RY AT WORK 49.900 1 ^ ' Yes 0 Na a DATEOF DEATH A/o D.r 45 Decewber 20, 2004 27D DATE SiGNE0 68 Da 5' 1 M DOLE : LAST Rathaan Mayer CONDrONS - Co mAc o/eun946*0 4OM r*1 *Med 21c TIME OFDEATH 201803817 CERTWICATE OF DEATH Ss AGE - Lam 4*414*5 _ VN OER 1 Y EAR -UNDER 1 065 Iws I 6 8 5D MOS 1 DAVE 5c tKh1RS Y O 6r.- PL �CE OF DE ATH NOSP:TA ❑ InpraaV 0 9c. CITY. TOWN OR LOCATION 93 STREET AND NUMBER ancitaM9 245 Coa61 Grand Island 11121 W. Koenig 68801 Self Employed 12 PADDLE LAST Mayer 19a INFORMANT • NAME IST6ET OR RF 0 NO.. CRT OR TOWN STATE. ZIPI Koenig, Grand Island, Nebraska 68801 21a METHOD OF IMPOSITION 212. DATE 21c CEMETERY OR CREMATORY : NAME . 11071 ®B AAI ❑ Removal Deo8111:1et 23, 2004 Grand Island City Came 210 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE 26c AMR OF INJURY :4 i p 03 TO+1V:'dalP 1177m- *6daNd9e dM4 acti x11111* WM. ORO and man sad 6. a 4 COMICIMMI ■S'g*ta6 wA TAW" DID TOBACCO U5E CONTRIBUTE TO THE DEATH? NO ❑ UNKNOWN IS 64 INSIDE CITY LM6n vast Q No 17,, 60 PART PO IF WAS TNEMA 2A AUTOPSY PREGNANCY W THE PAST 3 MONTHS' {� { 1!P4es 10 -5411 TAF f ' NO ❑ Yes n- 266 DESCRME HOW - W..1RY OCCURRED M AND ADDRESS OF CERTIFIER IPHYSIC6w, CORONER S PHYSICMN OR COUNTY ATTORNEv1 [Type aP COUNTY OF DEATH Hall FIRST Linda AN Karen Mayer DAt5 SWNED /6b DOs r, 0 3 -cam 26c PRONOUNCED DEAD Ada Ow 771 Der 2a, 2004 Nursr15 Nome Res.ence STANLEY.. COOPER V ASSIST STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 3 DATE OF DEATH AMA Dar WW1 December 20, 2004 6 DATE OF 6WTH abaft Dorm 6•61 Septastber 19, 1936 0 as. ,50ecdr, MAIDEN SURNAME Hathmaa Imo* bassoon oval and dear unknown wry oeanm a.U1a11 ` I 6564a1 .***68 deal' WAS CASE REFERREOP STAMMER O Yes I � '... LOCATION OR RF.D NO CITY OR TOY* STATE 262 T*E OF DEATH 10 pm 266. PRONOUNCED DEAD /wow 6:56 am 2fe Onam. Amid asa,7.mlam and anr*a9aw1 n my OPmeO, 0SI6 wowed a 611 0111111 011126 APO 01.1101719 i C111010174 III") I5*.4*. TIN . 4 ► IJ • lit= C I rtt 36 1 HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' f D WAS CONSENT GRANTED? YES NO ❑ YSS NO Sgt D Vitera, GIPD 131 S Lo st, Grand Island, NE 68801 726 DATE FILED BY REGISTRAR Alb. Dar ri1 JAN 7 2005 5a INSDE CITY LOWS Yw. ® �':❑ C CO cp Q