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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
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />9/6/2016
<br />LINCOLN, NEBRASKA
<br />20210194
<br />SERVICES, VITAL
<br />ate
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Herbert Ferdinand Heider
<br />2. SEX
<br />Male
<br />lltaIirgi4
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 24, 2016
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />359-22-4702
<br />5e. AGE - Last Birthday
<br />(Yte)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Good San)arRart:Society-Grand Island Village
<br />90
<br />6b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑; ER/Outpatient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />8. DATE OF BIRTH (MO.;Day,Yr.);
<br />December 29, 1925
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedents Home
<br />❑ Other (Specify)
<br />0 Hospice Facility
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN.
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />4055 Timberline St.
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY :LIMITS
<br />® YES ❑ NO
<br />100. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Marded, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF. SPOUSE (First, , Middle, Last, Suffix) If wife, give maiden name
<br />Joanne Lau
<br />11. FATHERS -NAME (First, Middle, Last, Suffix)
<br />Ferdinand Heider
<br />12. MOTHER'S -NAME (First, Middle, Maiden Sumame)
<br />Clara Dankert
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unit.) Yes 12/29/1948-01/04/1954
<br />15. METHOD OF DISPOSITION
<br />® 8urtal ❑ Donation
<br />❑ Cremation 0 Entombment
<br />❑ .Removal ; 0 Other (Specify)
<br />14a. INFORMANT -NAME
<br />Bill Heider
<br />16a. EMBALMER -SIGNATURE
<br />Gwen K. Hvronemus
<br />16b. LICENSE NO.
<br />1448
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />16c. DATE (Mo., Day, Yr.)
<br />August 29, 2016
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Cemetery Grand Island
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Livinoston-Sondermann Funeral Home. 601 N. Webb Road. Grand Island. Nebraska
<br />1m zip- code
<br />re -
<br />W
<br />U
<br />E
<br />0
<br />CAUSE OF DEATH (See instructions and examples)
<br />1$, PART I. Enter the:Oain of everts- diseases, Injuries, or complications -that directly caused the death, 00 NOT enterMnoinal events such as cardiac arrest,
<br />tatipiratOry arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Cardiopulmonary Arrest
<br />disease or condition resulting
<br />in death) _.
<br />Sequentially list conditions, if
<br />any, loading td the Cause l eted
<br />on line a
<br />Enter the UNDERLYING CAUSE
<br />(giwafe Or injury that Inittatld
<br />the events reauainp In death)
<br />LAST'
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />4 to6 Minutes
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />b) Old Age„
<br />onset to death
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />Years
<br />18. PART II.OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART 1.
<br />Chronic Obstructive Lung Disease, Hypertension, Diabetes Type 11, Coronary Artery Disease, Hypothyroidism, Chronic
<br />Adynamic Ileus
<br />20. IF FEMALE:
<br />❑ Not pregnant within petit year
<br />0 Pregnant et time of death
<br />0 NM pregnant, but pregnant within 42 days of death
<br />❑ Net moo. }p hot pregnant. 43 days to 1 year before death
<br />El Unknown H pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />21a. MANNER OF DEATH
<br />N 1 ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />❑ Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />2164 IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 24, 2016
<br />11;
<br />O fid. To the bast of my knowledge, death occurred al the time, data and place
<br />iand due to the cause(s) stated. (Signature and TNM)
<br />1 Jane: A. McDonald, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? YES 26a. HAS ORGAN OR TISSUEI DONATION BEEN CONSIDERED?
<br />NO ❑PROBABLY ❑UNKNOWN ❑ YES ONO
<br />23b. DAZE SIGNED (Mo., Day, Yr.)
<br />Auttust 24, 2016
<br />23c. TIME OF DEATH
<br />06:40 AM
<br />t
<br />8
<br />W Z
<br />24e. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis d examination and/or investigation, in my opinion death occued cause(s)rred e
<br />the time, date and place and due to the stated. (Signature and TM)
<br />0 fij
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO ❑ YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />28a. REGISTRARS SIGNATURE j6-��
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 29, 2016
<br />
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