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Q f rn n n T = D C� C? fn C!) ►-, G7 - p -in M CA --e cc _j N p Tc'a p �. O C co CD (h F—+ w p C N Suite 3, Brentwood By- The -Lake Condominium Property Regime II, Grand Island, Hall County, NE �G WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN-SERVIC SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL _ THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST`f1 THE LEGAL DEPOSITORY FOR VITAL RECORDS. " - - DATE OF ISSUANCE JUL 12 2000 200108407 A - LINCOLN, NEBRASKA HEALTH AND HUMAN _ STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HIlMAN V! VrrAL STATISTICS = CERTIFICATE OF DEATH -- - -- - - I It i'ENT NAi,c FIRST MIDDLE LAST 2 SEX; '- 3 DATE OF DEATH Monrr LORETTA (NMN) TAGEL Yes � N. ❑ mall - 'Fpmnitl _ COUNTY 2 July 2000 kCITY AND STATE OF BIRTH /tl not n USA. name country) Sa. AGE -Last Birthday UNDER t YEAR UNDER 1 DAY 6. DATE OF BIRTH Month. Ddk veal 5b. MOS DAYS 5C. HOURS MINS Norfolk, NE lyrs1 76 22 Sept 1923_. I ' SOCIAL SECURTIY NUMBER 16 FATHER NAME FIRST MIDDLE Ba. PLACE OF DEATH HOSPITAL inpatient 17 MOTHER FIRST MIDDLE MAIDEN SURNAME OTHER ® Nu 111, Hp n,• 508 76 9530 Elizabeth Rotherham 18 WAS DECEASED EVER IN US. ARMED FORCES' _ ___ _._ 19a. INFORMANT - NAME IYes no n, unk I I III yes . qwe war and dates of servlcesl No 28a DATE SIGNED (Mo.. Day v, ❑ ER Outpatient ❑ Residence 8b FACILITY Name Ill nor �nsbtutron, give sheet and number) Tiffany Square Care Center 21 a. METHOD OFDISPOSITION 21b DATE 21c CEMETERY OR CREMAT17RY NAME I ❑ DOA ❑ OmeriSoenn r L_ n Ti DUE TO, OR AS A CONSEQ(UEENNCE OF ` - -- - -- - - DUE TO OR AS A CONSEQUENCE OF Int val between onset I ICi OTHER SIGNIFICANT CONDITIONS - Condilrons contributing to the death but rid related PART III IF FEMALE. WAS THERE A gC FIT ' TWIN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS 8e C NTY OF DEATH i i-1 Island Yes � N. ❑ mall - 9a RESIDENCE - STATE _ COUNTY 9e. CITY. TOWN OR LOCATION 9d STREET AND NUMBER 1Ic,1,ding Zp Coder — r9e. INSIDE CITY LIMITS Nebraska 19b Hall 7 Grand Island 2745 Lakewood Dr. 68803' Yes [� Na ❑ 10 RACEg Il ee ggv. White. Black. American Indian 11 ANCESTRY leg Italian. Mexican, German, etc) t2. ® MARRIED ❑ WIDOWED 13 NAME OF SPOUSE /u -1, give maden name) e1cId Lll".1. 'ift6lrican NEVER DIVORCED Ludwig V. Tagel_ MARRIED 14a USUAL OCCUPATION /Give kmdol work done during most III) KIND OF BUSINESS INDUSTRY 15 EDUCATION ISi only Nghesl grade Completed) - ol wo,leng ide. even it,elredl Homemaker Elementary or Secondary IAi College ' 1u -,- Homemaking 16 FATHER NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Joseph E. Thramer Ho" icide tnve511ga110n Elizabeth Rotherham 18 WAS DECEASED EVER IN US. ARMED FORCES' _ ___ _._ 19a. INFORMANT - NAME IYes no n, unk I I III yes . qwe war and dates of servlcesl No 28a DATE SIGNED (Mo.. Day v, Ludwig V. Tagel 19h INFORMANT MAILING ADDRESS ISTREET OR FI F.0 NO.. CITY OR TOWN. STATE. ZIP) y i ° 2745 Lakewood Dr., Grand Island, NE 68803_ _ 0 EMS MER SIGNATURE B i- ICENSE NO 21 a. METHOD OFDISPOSITION 21b DATE 21c CEMETERY OR CREMAT17RY NAME it ® Banal ❑ Removal '� 6 July 2000 St. Anthony Cemetery iI..-�-q (.ITS OR TOWN STATE 72a FUNERAL H IE - NAME 21d CEMETERY OR CREMATORY LOCATION Huf fman' s Snider Chapel ❑ Cremation ❑ Donator Ewing, NE -- , f� • \1 Signature and Title) 0 —^x ` \ ` r�•� — ?21b RJNERAL HOME ADDRESS ISTREET OR R.F.D NO CITY OR TOWN. STATE. ZIP, Clearwater, NE, M/A Box 199, Elgin, NE 68636_ _ 23 ,MME TE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR ial. Ibl. AND lch Ierval between onset and near - w PART \�/� ❑ YES NO I. ❑ YES NO UNKNOWN r L_ n Ti DUE TO, OR AS A CONSEQ(UEENNCE OF ` - -- - -- - - DUE TO OR AS A CONSEQUENCE OF Int val between onset I ICi OTHER SIGNIFICANT CONDITIONS - Condilrons contributing to the death but rid related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL pggT PREGNANCY IN THE PAST 3 MONTHS' EXAMINER OR CORONER' tl , )Ages 10 -541 Ves NO Yes No __Yes ❑. NO � - -. _- '5a 260 DATE OF INJURY /MO.. Day. YrJ 26c. HOUR OF INJURY 26d DESCPBE HOW INJURY OCCURRED I A..cdern � Uncelarminetl ;ucne Pendlnq 26e INJURY AT WORK 281. street factory DOldingJeleV 26g LOCATION STREET OR R.F.D NO CiTV OR TOWN STATE ❑ ❑ OX1ce (Se,j.larm. Ho" icide tnve511ga110n Yes No _ ___ _._ 27a DATE OF DEATH /MO Day vr.l 28a DATE SIGNED (Mo.. Day v, 21 TIME OF DEATH y i ° - 27b DATE SIGNED (Mo. Da(y ti 27c. TIME OF DEATH . _aQr 28C PRONOUNCED DEAD IMo Day li 28d PRONOUNCED DEAD !Noun 28e On the basis of examination and or Invesngauon, m my opinion death occurred at the time. date and place and due to the causels) stated. S v - 27d To me best of my knowle qe death oc red at the ate and Dlace a dGue to \ Causelsl staled. \y1 g ° ° , f� • \1 Signature and Title) 0 —^x ` \ ` r�•� (Signature and Title III. 29 DID TOBACCO USE CONTRIBUTE TO THE DEATH' 30.8 HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 30.b WAS CONSENT GRANTED' ❑ ❑ YES NO (p� ❑ YES L'/Y NO ❑ YES NO UNKNOWN -'��''��` 71 NAME AND ADDRESS OF CERTIFIER IPHYSCCIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY, (Type a Pnnry- John Cannella, M.D., 729 N. Custer Grand Island NE 68 32a REGISTRAR 32b. DATE FILED BY REGISTRAR /Mb. Day Yr/ 11 1 1111 1