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<br />i!N1+4ytg9ft;�,pe4gVAVaaSTATE OF NEBRASKA � � aarrrrq (1NbrE/rt.(�ri4r(I r(pP}&�i§ A
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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 0��dika
<br />vce
<br />DATE OF ISSUANCE
<br />LINCOLN, NEBRASKA
<br />20210f/54
<br />Sarah Bohnenkamp
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OFNEE1RASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />CERTIFICATE OF DEATH
<br />N4g1 001.6.44111,
<br />n (�(4;0.9.Sl err
<br />TO No CompletediVetdled by: FUNERAL DIRECTOR:
<br />1. DECE QEMT'S-NAME (Fin. Middle. Last.. Suffix)
<br />William Lew Gerbig
<br />2. SEK
<br />Male
<br />V 1 V..V Vy
<br />3.DATE OFOEATN (Mo..Day, Y..)
<br />Oct. 11,2007
<br />4. CITY AN0 STATE OR TERRITORY OA FOREIGN COUNTRY OF BIRTH
<br />Sa. AGE -Last Birthday
<br />6h. UNDER I YEAR
<br />Sc. UNDER 1 DAY
<br />9. DATE OF BIRTN (M... Day.Yin
<br />Gram Island, Nebraska
<br />(Yrs.) 75
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />March 21, 1932
<br />?.SOCIAL SECURfTY MJMBER
<br />508 -30.- 42.8 5
<br />Ba. PLACE OF DEATH.
<br />HOSPtTAI : U lenient ream �i Nursin9Hannl1C ❑Napicefs96hy
<br />6D FACILITY. NAME :(11 not MAIllulion, giro shoal and number)
<br />Grand Isl.and'Veterans Home
<br />,.
<br />0 ERNOulpallsnf 0 Decedent's Home
<br />o DDA Ooina(Sp�y)
<br />6G CITY OA TOWN OF DEATH (Include Vg
<br />Grand Island 68803
<br />6d. COUNTY OF DEATH
<br />Hall
<br />SeiRESIDENCE-STATE
<br />Nebraska
<br />1b.000NTY
<br />Hall
<br />9a C11YOR TOWN
<br />Grand Island
<br />pd51REETANONIafBER
<br />1724 N. Park
<br />9.. APT. NO
<br />.
<br />91. TIP CODE
<br />68803
<br />99. INSIDE CITY' WAITS
<br />IA YES a No
<br />10a. MAR1Tal STATUS ATTIRE OF DEATH X) Melded 0 Nem Married
<br />0Yarned,bAleo mted.0Widowed 0, !Ammon 0Unlnwwn
<br />10b. NAME OF SPOUSE (First. Saddle, Last. Suflla) N wile giro maiden name.
<br />Virginia L. Sorensen
<br />1I.FATHER'S+NAME (Ftril. Middle. Last, Subic)
<br />William G. Gerbig
<br />12. MOTHER'S -NAME. (Pint.. Middle, Maiden SumIA.)
<br />Lillian S. Spencer
<br />Tal VEH)NU.S. ARMED FORCES? Give dales of sonde. m yes.
<br />(Y.# « tine. ) 11/1953-W31/1955-
<br />tea INFORMANT -NAME
<br />Virginia L. Gerbig
<br />14b. RELATIONSHIP TO DECEDENT
<br />wife
<br />-15.t)ETHOO OF DISPOSITION
<br />El Sorsa °Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not. Embalmed '
<br />16b. LICENSE P.
<br />16c. DATE (Ma.. Day, Yr. I _.
<br />10/11/2007
<br />t01cm,,tlpri" QENewWnem
<br />URemoual OOIher)Speuryr(
<br />1Ad. CEMETERY, CREMATORY OROTHERLOCATION CITY /TOWN STATE
<br />Central Nebraska Cremation Service, Gibbon, Nebraska
<br />Ile FUNERAL HOME NAME AND WILING ADDRESS (Sired. City or Town. Steel 1 7b. Zip Cod.
<br />All Faiths Funeral Home, 2929 S. Locust St., Grand Island,NEI 68801................
<br />CAUSE OF DEATH (See instructions and examples) 1'
<br />Ca
<br />IL
<br />2
<br />�Eq
<br />f}i
<br />16 RAF I 1 En1.r the a1AID9l.YlpIo. di , inju.i.R INcdmplcnions-Ihal directly caused tha death. DO NOT treat terminal adds such as cardiac erred, ; APPROXIMATE INTERVAL
<br />meplmlory arrest. or renlrkuinv Iibra ve n wimple( ahoei ng m,.1101ogy. D0 NOT ABBREVIATE Enter only one cause on. an.. Add additional Inas l necetsary. t
<br />IIIMEDLWE CAUSE: : onewmdeath
<br />i r
<br />geMEDU,tYrewsE(!Y i w . PnelIMCnia 1 1 Week
<br />dine, oeeandie011.1 ng OUE TO, OR AS A CQNSEOUENCE OF: 1 0new To MHO
<br />Ade et) I
<br />I
<br />gmewlMinetconaNene.9 �1 t
<br />MFAIIMFg eNeceea.eaed DUE TO:OB AS A CONSEQUENCE OF: 1 onsetM dealt
<br />Etas MAIMIDERI IBI CAUSE
<br />(BwseorM)4rythalinlVeled (c). t
<br />9ewrymerawlingin& S DUE TO.OBAS A CONSEOUENCE OF: 1 onsw10 death
<br />{AST I
<br />FA I.
<br />re PART 11. OTHER SIGNIFICANT CONDRIONS.Condlltom nenlrIbuling 10 Ina death but not resulting in the enderlyh1g Coes* given In PART 1.
<br />Coronary Artery Disease, Cerebrovascular Accident.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />O YES RI NO
<br />*IF FEMALE:
<br />0 NO tognAMrfallinputyaar
<br />(�:�Pragnanr n 10111101
<br />21&4ANNEROF DEATH
<br />yi Natural OHoratio. :
<br />0 Accident Pending hwesagalfan
<br />2)b. IF TRANSPORTATION INJURY
<br />UDdvPoOpwaer
<br />0Psstengw
<br />21e. WAS AN AUTOPSY PERFORMED*
<br />C1 YES ANO
<br />.death
<br />ONd pregnenl, but pregnant +iahin e2 days olduln
<br />0 Not pregnant Patagonia.43 days to I year befog duel
<br />0 pwn ii pre9anloAlhin the pall Year
<br />°Suicide 0 Could not be deemdned
<br />0 Pedestrian
<br />❑ Other (Spicily)
<br />.
<br />ltd. WERE AUTOPSY FINDINGSAVALABLETO
<br />COMPLETE CAUSE OF DEATH?
<br />0 YES 0 N0
<br />22e. DATE OF INJURY (Ma. Day. Yr.)
<br />220. TIME OF INJURY.
<br />m
<br />22c. PUCE OF INJURY -At Immo. Karn,
<br />shill. fader 9, dike bulldog, conwruelion
<br />rte. etc. (Spicily'
<br />22d. INJURY AT WORK?
<br />Urea clue
<br />`22e. DESCRIBE HOW INJURY OCCURRED
<br />HLLOCATI0N Of INJURY. STREET. a NUMBER. APT. NO CITY/TOWN SWE DPCODE
<br />23e DATE OF DEATH (Mo.. Day. Yr.)
<br />October 11, 2.007
<br />=
<br />Egg
<br />208. DATE SIGNED (Mo. Day, Yr.)
<br />2401511 DEATH
<br />m
<br />i
<br />29hDATESIGNED (M0. Do Yr.)
<br />Octcaber 11, 2007
<br />226,TIMEOFDEATH
<br />I 5:45 A. m
<br />I
<br />'Cao' 6
<br />240, PRONOUNCED DEAD (A6,Day, Yr.)
<br />Zed.TIME PRONOUNCED DEAD
<br />al
<br />E
<br />a
<br />~
<br />22d.Yo Ila dew w my AnowleaW deem occur M w lA.len.. dale ltd P e 1.
<br />'-- end etre b1M cewNal .1.4.4'. )SigrnHo. anti Titin) ♦ E
<br />Amo
<br />.S . , NAG' ICAti110"1
<br />Zee On tle Cash 0t. aaAlrlltrpn 10W Nrasmgauan. in cry opiaon deam.eWrrsdaf
<br />1014100.00110.19 place and 00. b me uusNs) edema 15ngnahm0 once Tae J �''
<br />2SA14TOaAG00USE CONTRIBUTE TOTHE DEATN?
<br />2 Y55 0 NO p PROBABLY 0 UNKNOWN
<br />26a.HAS ORGAN ORTISSUE DONATION BEEN CONSIDERED?
<br />I 0 YES NO
<br />266. WAG CONSENT GRANTED?
<br />Not Applicable a 26.1s NO 0 YES 0 NO
<br />27iNAM1,TTELE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typed Prole)
<br />Jennifer King, M.D.,2300 W. Capital Ave., Grand Island, Nebraska 68803
<br />2OaREWSTRAR'SSIGNATIMIE (� /;0F011,
<br />�(j %fxg, l!! t,
<br />2eh.DATE FILED BYREGISTRAR IMa,Day 11:)
<br />OCT 15 2007 I
<br />CD
<br />N
<br />CO
<br />
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