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Rev 11/97 <br />I- <br />z <br />W <br />0 <br />W <br />U <br />W <br />0 <br />LL <br />0 <br />We <br />i <br />Q <br />z <br />6 <br />Cl) <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT <br />VITAL STATISTICS 200108520 <br />nan"VlrflAT= nV nCATU <br />t. DECEDENT - NAME FIRST MIDDLE LAST <br />2 SEX 3. DATE OF DEATH /Abmh. Day y"F) <br />Adolph Ben Lukesh <br />Male I April 13, 1998 <br />s. CITY AND STATE OF BIRTH /n rtdh US.A,. name counhyl Ss. AGE -Lost Birthday UNDER t YEAR <br />UNDER 1 DAY S. DATE OF BIRTH /Md1M1, Day Year) <br />(YrsI 90 5b. MOS. I DAYS <br />Sc. HOURS' MINS. August 6, 1907 <br />Ord, Nebraska 7 <br />7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH <br />[] lnpaherd OTHER ® Nursing Home <br />HOSPITAL <br />507 -48 -5621 --- -_ <br />❑ ER Outpatient ❑ Residence <br />Sb. FACILITY - Name In rraf malnunat give ahM/ and numbed <br />E] DOA Other /SW lfvl <br />❑ <br />Lakeview Nursing & Rehab Center <br />Sc . CITY. TOWN OR LOCATION OF DEATH ad, INSIDE CITY LIMIL F DEATH <br />Grand Island yes ® No Hall <br />9e. RESIDENCE -STATE 9b COUNTY .. N OR LOCATION TREET AND NUMBER /Including Zip Codel ge. INSIDE CITY LIMITS <br />Nebraska Hall Grand Island 223 W. Anna 68801 Yas ® Nb <br />10 RACE - a.g.. White. Black. American kWian. I1. ANCESTRY le.g.. Mellen. Mexican. German, etc) 12. WIDOWED 13 NAME OF SPOUSE (n x ib. On'a maiden Rams) <br />eta) lSOecily) (S�NI DIVORCED Estelle Sonnenf eld <br />White American <br />its USUAL OCCUPATION (Give kind d work done dvnn9 naval llb. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only ade cwr~) <br />ary gt <br />rev 10 -121 College 1 t -1 a 5• I <br />d waking O,e, even it reared/ EJQ <br />tp <br />r <br />Agriculture jj h G ad <br />Farmer <br />-FATHER- MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />16. NAME FIRST <br />s William A. Lukesh Ann NMN Hrd <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />fee, INFORMANT - NAME <br />(Yes m. or unk.l Ih yes give war and dales of serviceel <br />Estelle Lukesh <br />NO -- - - - - -- <br />19b. INFORMANT MAILING ADDRESS ISTREET OR R F D. NO.. CITY OR TOWN. STATE. 21P) <br />1 A a, rand Island, Ne. 68801 <br />20 E MER - SIGNATUiiEB C NO. r,5;4 /11 21a. METHODOF DISPOSITION 21b DATE 21e. CEMETERY OR CREMATOR' NAME lip <br />// ©Burial E] ;a Apr. 17, 1998 Westlawn Memorial Park <br />21tl. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />22a. FUNERAL AME <br />Livin ston- Sondermann F.H. ❑D` °m°'b ❑°oa °°• Grand Island Nebraska <br />22b. FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. LP) <br />601 N. Webb Road, Grand Island, Ne. 68803 -4050 <br />1 interval between onset and death <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER UNE FOR lal. lb). AND (c)1 I <br />PART V <br />I� <br />I <br />�l (al 1 Mlerval between a and Math <br />DUE TO. OR AS A CONSEQUENCE I <br />. 1 <br />- 1 <br />(b) I Interval bet"" Or" and Math <br />DUE TO, OR AS A CONSEQUENCE OF: , <br />Icl <br />MINER OR CORONER MEDICAL <br />OTHER SIGNIFICANT CONDITIONS - CorWhi contributing to the ath but not related PART III IF FEMALE. WAS THERE A ' 24 AUTOPSY E WAS CASE REFERRED TO <br />PART PREGNANCY IN THE PAST 3 MONTHS -4-- 1/7SA <br />/f <br />6 - / / - (Ages 10 -541 Yes F I No F Vaa No �{ vss No <br />26a <br />26b. ATE OF INJURY .. Dey ./• <br />26c HOUR OF INJURY <br />26d, DESCRIBE HOW INJURY OCCURRED <br />Accident Undetermined <br />M <br />El Suicide Pending <br />26e. INJURY AT WORK <br />261. ofice EtrOFhNJURV - A111o�1, farm. street, factory <br />6 Ind nc 3 <br />26g. LOCATION STREET OR RF.D. NO. CITY f�i TOWN STATE <br />F1 Homicide Investigation <br />Yes ❑ No ❑ <br />g <br />27e. DATE OF DEATH /MO.. Day Y11 28a. DATE SIGNED (MO. Day. Yr) 26b. TIME OF DEATH <br />Aril 13 1998 a M <br />27b. DATE SIGNED lido. Day Yrl 27c TIME OF DEATH C 28: PRONOUNCED DEAD /MO. Day. YrI 28d. PRONOUNCED DEAD (Hour) <br />April 15, 1998 � 2:45 PM M M <br />L_ <br />$g s <br />e I! 27d To the Des) d my knowledge. Math occurred at the tlme. dale place and due a 28e. On Me basis Of exam. &inn and a kwastpatbn, in my opinion deem occurred of <br />~ b me time. date and d�e and due to me causes) stated. <br />s yuse(sl stated. .- <br />S' nakxa and TIIte <br />(Signature ' and T' <br />29 DID TOBACCO USE CONT TE TO THE EATH 30.8 HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? <br />e, ❑ YES NO ❑ UNKNOWN ❑ YES NO -� ❑ YES NO <br />31. NAME AND ADDRE68 OF CERTIFIER IPHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI (Typ►p <br />X' MDT 800 Alpha Street, Grand Island .Ne 68803 <br />ji* ne A McDonald <br />32b DATE FILED BY REGISTRAR (two.. Day. Yr.) <br />32a. REGISTRAR <br />to <br />hereby <br />S cert�ir .. <br />fate of Nebraska <br />.` c �l!Lil ile <br />Signe d in m <br />Y prase;) <br />I U0,11C <br />