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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 RECORDS ,
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />LINCOLN, NEBRASKA AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />IM 1S IANCE
<br />202103857
<br />CERTIFICATE OF DEATH
<br />972
<br />v
<br />a
<br />' Edi
<br />i
<br />ts. f4ETHDt7 DPr sPO$I ION
<br />Butial [] Donation
<br />1. DECEDENTS -NAME (First, Middle Last, Suffix) SEX 3. DATE OF DEATH (Mo Day Yt ')
<br />Galen Ernest Lanibreefit • -
<br />,Male Augllst113, 2019 •
<br />4 CITU 6M"S RTA.,„ (11? +Corot rrnv. rp C .ctr.1 hntirwroY nc pi ru I 1 f ^r _ - CL... IRF L .-_ : •.-.:.,.n tic. C.`L_' I '.7 . C., . _ .:� �: ,..
<br />:- T t :,+Tat Y./
<br />^re) DAYS HOURS' MINS.
<br />Hastings, Nebraska 72 rHOS.
<br />' I February 3, 1947
<br />7. SOCIAL SECURITY NUMBER
<br />506-58-8614
<br />Sb. FACILITY -NAME (1f not Institution, give street and number)
<br />Southlake Village Rehabilitation & Care Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Lincoln 68526
<br />8a. PLACE OFDEATH
<br />HOSPITAL 0 Inpatient
<br />] ER/Outpatient
<br />DOA
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Lancaster
<br />❑ Hospice Facility
<br />9e. RESIDENCE -STATE
<br />Nebraska
<br />8d. STREET ANTI NUMBER
<br />56785 714th Road
<br />9b. COUNTY
<br />Jefferson
<br />9c. C)TY OR TOWN
<br />Fairbury
<br />9e. APT. NO.
<br />9f. LP CODE
<br />68352
<br />9g3 Bi$iDE CITY JMrr$
<br />YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />[3 Married, bntseparated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First. Middle, Last, Suffix) If wife, glve maiden name
<br />Harriet Lambrecht
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Waldemar Lambrecht
<br />12. MOTHER'S -NAME (First, Middle,
<br />Maxine Ohlman
<br />Maiden Surname)
<br />13. EVER IN U.S. ARMED. FORCES? Give dates of service if Yes.
<br />(Yee, No) or Unit.) No
<br />14a. INFORMANT -NAME
<br />Harriet' Lambrecht
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16a. EMBALMER -SIGNATURE
<br />L. Todd Biester
<br />❑ Cremation 0 Entombment
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />❑ Removal © Other (Specify)
<br />Concordia Cemetery
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Aofet Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />1$b. LICENSE NO.
<br />1152
<br />16c. DATE (Mo., stay, Yr.)
<br />August d, 20i9 "
<br />CITYITOWN
<br />Juniata
<br />STATE
<br />Nebraska
<br />170. Zip Coda
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />13. PAWL Enter the chain of events- diseases, Injuries, or complications4tat directly caused die death. DO NOT enterlamdltal events such es cardiac anrsst,
<br />IMMEDIATE CAUSE (Final
<br />gdisease or condition resulting
<br />in dead)
<br />Sequentially list conditions, if
<br />any, kidding to thacause gslad
<br />respiratory arrest, or sentrieuler fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause ori a line. Add additional lines N necessary.
<br />a
<br />d
<br />a
<br />c
<br />N
<br />Enter the UNDERLYING CAUSE
<br />.(disease or lnJury.that initiated:
<br />the
<br />eyelids tlsukipg In death) •
<br />LASE
<br />IMMEDIATE CAUSE:
<br />a) Brain Cancer
<br />DUE TO, OR AS A CONSEQUENC OF:
<br />b) Unknown
<br />onset
<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 />onset
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />YES ❑ NO
<br />iC. FErkALE:
<br />❑ Not peignart Within dost year
<br />0 Pregnant at time of death
<br />Nat pregMtrt,,but pregnant within 42 days of death
<br />❑ i40 m :hip eirenrient 48 days to 1 year before death
<br />❑ Unknown it ptagmnt within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES Q NO
<br />.1r. fJ N2n OF 1:41'..."
<br />.T!'
<br />® Natural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide 0 Coult1 not Co determined
<br />22b. TIME OF INJURY
<br />_ fie To-oeSPORreTine!ft'..:ovl
<br />❑ DAver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />:.❑ Other (Specify)
<br />.1c. tents Aa! A(tTeMSY P oFEyR,'i,1501
<br />❑ YEs ® No
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OFDEATN?
<br />❑ YES ❑ NQ
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<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 3, 2019
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />August 6. 2019 01:47 AM
<br />3d. To the nest of my knowledge; death occurred et the time, date and plata
<br />and due to the cause(s) stated. (Signature and TNN)
<br />Jef res . ,tarrett MD
<br />2S61151ObACCITUcc. ir..mcu is-`.".'� CL"_' 4' sea Has ORGAk4
<br />❑ YES g] NO 0 PROBABLY ~ 0 UNKNOWN 1 ❑ YES
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Jeffrey E. Jarrett,; MD, 1500 South 48th Street, Suite 800, Lincoln,
<br />24a.;DATE>SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />s
<br />a -I
<br />Pig
<br />ir 2 24e. On the basis of examination and/or investigation, In my opinion death «cured k
<br />8 g the time, date and place and due to the cause(s) slated. (Signature and TNN)
<br />g
<br />TI'.,'3'.IE.D!1NATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED/
<br />g NO 'No: Amami -min sale rt.'AG ❑ r:
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />28e. REGISTRAR'S $(Gt:ATURE
<br />Nebraska, 68506
<br />28b. DATE FILED BY REGISTRAR (MO Day, Yr)
<br />August 8, 2019
<br />
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