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<br />t STATE OF NEBRASKA > "�
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<br />WIKEN THIS 'COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES tTHE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SVICES, VITAL
<br />RECORDS.OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS tta
<br />JI.BIftNLW ¢¢JJ
<br />DEC 2F016` SSUANCE 2 202007351 ASSISTANT STATE REGISTRAR
<br />S. COOPER
<br />--DEPARTMENT HEALTH AND
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />CERTIFICATE OF DEATH Q7 32004
<br />3. DATE OF DEATH (Mo., Day,Yr.)
<br />October 28, 2007
<br />HUMAN SERVICES
<br />g
<br />ir: Western Hall County Good Samaritan Center
<br />a.: 6t. CITY OR TOWN OF DEATH (Include Zlp Code)
<br />Wood River 68883
<br />Bt.RESIDENCE.STATE
<br />Nebraska
<br />mi ad. SUtEETANDNUMBER
<br />II 14011 East St'
<br />t0a_ MARITAL STATUS AT TIME OF DEATH ❑ Mauled ❑ Never Named
<br />1i
<br />❑ Manned, but sepals U Widowed al Divorced O Unknown
<br />m 11. FATHER'S. NAME (First, i Middle,
<br />Lester Geiger
<br />13. EVER IN U.S. ARMED FORCES? Give dales o1 service If yes.
<br />1. DECEDENTS -NAME (First, Middle,
<br />Donald Dean Geiger
<br />4. CITY AND STATE ORTERRITQRY, OR FOREIGN COUNTRY OF BIRTH
<br />Last, Sultix}
<br />2. SEX
<br />Male
<br />Farwell, Nebraska
<br />SOClALSECURITY NUMBER.
<br />505.42-3751
<br />5a. AG E-Laat Birthday
<br />(Yrs.)
<br />8b. FACILITY•NAME (II riot Institution. give street end number)
<br />eb.COUNTY
<br />Hall
<br />(Yes. Do, orunk.I Ne
<br />15. METHOD OF DISPOSITION
<br />IBt Burch, D Donation
<br />❑Clemabon ❑Enlonnbmem
<br />❑etimoi 300iat(Sprclty)
<br />72
<br />5b, UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />Ia. PLACE OF DEATH
<br />)IOSPITAt t
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo.. Day. Yr.) j<
<br />January 3, 1935
<br />❑ Inpatient Q!1J ® Nursing Home/LTC ❑ Hospice Facility
<br />0 ER/Outpatient 0 Decedent's Home
<br />❑ Olrier(Specih) ..
<br />004
<br />Bd.COUNTY OF DEATH
<br />Hall
<br />OG CITY OR TOWN
<br />Wood River
<br />e. APT. NO
<br />M. ZIP CODE
<br />68883
<br />0g. INSIDE CITY LIMITS
<br />I YES 000'
<br />tOb. NAME OF SPOUSE (FIrsL MIddle. Last, Sulk) Il wire, Ore maiden name.
<br />Last, Sulllx)
<br />14a. INFORMANT -NAME
<br />Dan Pullins
<br />(6. MBALMER•8rG / J
<br />16d. CE METERY, CREMATOR OR OTHER LOCATId
<br />Elmwood Cemetery
<br />17a FUNERAL HOME NAME AND MAIL NG ADDRESS (Street. City or Town, State
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />12. MOTH£R'S•NAME (First,
<br />Dorothy Moeller
<br />l6b. LICENSE N0.
<br />/D7/
<br />CITY f TOWN
<br />St. Paul
<br />CAUSE OF DEATH (See instructions and examples)
<br />Middle. Malden Surname}
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />16c. DATE (Mo.. Day, Yr. )
<br />November 1, 2007
<br />10. PAM1.Enterthechamoleventa•-dlaeasee,In)udes,orcompliations--thatdirectycausedthedeath.D NOT enlertertMnatevenIssuch ascameo arrest
<br />respiratoiyarresl. Or ventAGllar 'Malls bon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a tine Add edditonat Arles 11 MOSES rt.
<br />IMMEDIATE CAUSE:
<br />O»04EcIATECAUSEIPtui
<br />any, leading to Mecums listed
<br />an mea
<br />Enter tie UNDEFILYPIGCAUSE
<br />(disease or Injury qW Inldeted
<br />the evmh moulting hdeath)
<br />Isr
<br />(a}
<br />DUE TO. OR A S A CONSEQUENCE OF:
<br />Ib) C`nYtrn c CevtNbvk..3
<br />DUE TO, OR AS A CONSEDUENCE OF:
<br />(c)
<br />DUE T0, OR AS A CONSEQUENCE OF:
<br />(d)
<br />zen sq
<br />10. PART B OTHER SIGNIFICANT CONDITIONS.Condl0ons contdbubng to the death but not res %tng In the undedying Coust given In PART 1.
<br />k ‘A ti -e ( Std r 1 Ckk...F.
<br />20. IF FEMALE: 40 1 Pt
<br />O Notptering willialpast year
<br />a Pregnant sl Omit or death
<br />❑ Not pregnant but pregnant wllhln 12 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before dealt
<br />( Unknown if pregnant wlltun the past year
<br />22a. DATE OF INJURY (MO., Day, Yr.)
<br />22dtINJURY ATWORK?
<br />❑,YES ❑ NO
<br />21a. MANNER OF DEATH
<br />VNatura! ❑Homtade
<br />O Acddent❑ Pending Investigation
<br />❑ Suldde 0 Could not be OeIemihed
<br />22b. TIME OF INJURY
<br />m
<br />225. DESCRIBE HOW INJURY OCCURRED
<br />22r. LOCATION OF MAIM. STREET d NUMBER. APT. N0.
<br />4
<br />0.=
<br />82°
<br />21
<br />23a. DATE OF DEATH (Mo.. Dap Yr,)
<br />10- Z'? -01
<br />2Ib. IF TRANSPORTATION INJURY
<br />Ddverl0peralor
<br />0 Passenger
<br />0 Pedestrian
<br />0 Ober (Specify)
<br />STATE
<br />17b. Zlp Code
<br />68801
<br />APPROXIMATEtNTERVAL
<br />onset to death
<br />1 cruet to death
<br />�7ycrrq
<br />1 *melba deem
<br />1
<br />I onset to deabt
<br />WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED%
<br />O YES YA NO
<br />21c. WAS ANAUTOPSY PERFORMED? .,
<br />0 YES IX NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY. At horde, taim, SUM, taCtdry, 410ce twllding, cantlnicaon site. e1C. (Specify)
<br />CITY/TOWN
<br />231LDATE SIGNED (160,, Day. Yr.)
<br />t tle-0Z
<br />23o. TIME OF DEATH
<br />/4t55m
<br />23d.To the best of OwRdge,
<br />and due to
<br />al me, dab and place
<br />btnadl )♦
<br />25. DIDTOBACGOUSE CONTRiBUTETO THE DEATH?
<br />❑ YES ❑ NO 1:KpROBABLY 0 UNKNOWN
<br />STATE ZIP CODE
<br />21a. DATE SIGNED IMO., Day, Yr.)
<br />21D.TIME OF DEATH
<br />0i
<br />W
<br />"8120
<br />bisz
<br />ui z O 24e. On tie basis of exardnalon and/or Investigation, In my opinion death occurred at
<br />F0 o the time, date and place and due to One cause(a) stated. (Stgnahne and Tlls) 7
<br />8
<br />21o. PRONOUNCED DEAD (Mo., Day. Yr.)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YESID
<br />21d. TIME PAONOUNCEDDEAD
<br />m
<br />m
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable II 26a Is NO 0 YES 3tN0
<br />7. NAM E. TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN ORCOUNTYATTORNEY) TypeorPnet)
<br />{,etter"e L. 44(4...,e M,D. 2.86, w. pose:.► #tea ra,,,nd Ts/a*1d, /V.6" 6OP3
<br />L) : 28a.REGISTRAR'S SIGNATURE ,. N • 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />Nov 13 2007
<br />
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