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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECO
<br />DATE OF ISSUANCE
<br />SEP 132018
<br />LINCOLN, NEBRASKA
<br />RUSSELL FOSLER
<br />INTERIM ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 3 0' 9 1 'f'
<br />(�FRTIFI(_ATF (1F fl ATN 08V J 1
<br />To Be CompletedNerifled by: FUNERAL DIRECTOR -----Z-111
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix) •
<br />Gertrude Mason Krull
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo.,Day,Yr.)
<br />October 17, 2008
<br />J 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE -Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Philadelphia, Pennsylvania
<br />(Yrs.)
<br />93
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />September 15, 1915
<br />7. SOCIAL SECURITY NOM ER
<br />182-01-2728
<br />89. PLACE OF DEATH
<br />HOSPITAL'0 Inpatient OTHER: ❑ Nursing HomeILTC 0 Hospice Facility
<br />8b. FACILITY -NAME Of not Institution, give street and number)
<br />Saint Francis Medical Center
<br />® ERIOutpatient ❑ Decedent's Home
<br />0 DOA Qomegspeeiry)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />89. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />913. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />303 E. Dodge St.
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />El Yes Q No
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married Q Never Married
<br />Q Married, hut separated 0 Widowed 0 Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, give maiden name.
<br />James :Krull
<br />11. FATHER'S -NAME (First Middle, Last, Suffix)
<br />Oswald Graham
<br />12. MOTHER'S -NAME (First, Middle, Maiden Sumame)
<br />Gertrude Mason
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or link.) No
<br />14a. INFORMANT -NAME
<br />James KruI)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />18. METHOD OF DISPOSITION
<br />®B al 0Donation
<br />EiCremation
<br />168. EMB ISMER-SlpN • (•
<br />/ ��
<br />UJ �'
<br />1613. LICENSE NO.
<br />/ 9 .7
<br />16c. DATE (Mo., Day, Yr.)
<br />October 22, 2008
<br />❑Entombment
<br />❑Removal QOlhar(speeity)
<br />169. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL NOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enterthe ;halo er event( - diseases, inludes, or complications -that directly caused the death. DO NOT enter terminal evepts such as cardiac arrest, 1 APPROXIMATE INTERVAL
<br />respiratory angst, or ventnaolar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cease on a line, Add additional linea If necessary. 1
<br />IMMEDIATE CAUSE: - onset to death
<br />IMMEDIATE CAUSE (Final I
<br />nldeathor condition resulting a) c"ardi opulmonary arrest 1 immediate
<br />1
<br />DUE TO, OR AS A CONSEQUENCE OF: i onset to death
<br />I
<br />Sectuentletly list conditions, IT., b) 1
<br />any, leading to 1tie cause listed
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: ) onset to death
<br />I
<br />Enter the UNDERLYING CAUSE c) I -
<br />(disease or Injury that Initiated
<br />the events resulting in death)<: DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />LAST I
<br />d) 1
<br />1
<br />18. PART IL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />gl YES .4Ei140
<br />20.1F FEMALE:
<br />❑Not pregnant within past year
<br />21a. MANNER OF DEATH
<br />1:21 Natural 0 Homicide
<br />21b IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ®NO
<br />❑ Pregnant at time of death
<br />0 Not pregnant; but pregnant within 42 days of death
<br />QNot pregnanl(but pregnant -03 days to 1 year before deathn
<br />JUnknown If pregnant within the past year
<br />0 Accident ❑ Pending investigation
<br />0 Suicide 0 Could not be determined
<br />0 Passenger
<br />0 Pedestrian
<br />❑Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES W NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 122b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, fans, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />225. LOCATION OF INJURY - STREET 8. NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />Attending PHYSICIAN
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)}
<br />T Q W
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />October 28,,20Q
<br />24b. TIME OF DEATH
<br />4:43 a m
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />m
<br />vNZ
<br />w j- O
<br />e, x t' r
<br />aa4 z,
<br />,.
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />October 17, 2008
<br />24d. TIME PRONOUNCED DEAD
<br />•4:43 P m
<br />23d. To' the best of myknowledge, death occurred at the time, date and lace cl K O
<br />9 p W Z
<br />and due to the cause(s) stated. (Signature and Title) a OZ O ':
<br />1- 00
<br />24e. On the dads otexamination a vestigation, In my opinion death occurred
<br />at the time, date and and due to the cause(s) stated. (Signature and Title)
<br />Deputy Hall
<br />o8
<br />County Attnrnpy
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />Q YES Q NO ❑;PROBABLY ® UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION aE.- CONSIDERED? .r
<br />0 YES El NO -
<br />26b. WAS CONSENT GRANTED7
<br />Not Applicable if 26a Is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Aaron J. Kunz, Deputy Hall County Attornev, 23 S. Locust St., Grand I.51 and. NF 6RRf1
<br />R
<br />28a. REGISTRAR'S SIGNATURE
<br />/(/„It/uy�/p,
<br />(_ A.
<br />//uJt
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />OCT 3 0 2008
<br />
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