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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT;,
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPO
<br />DATE OF ISSUANCE
<br />SEP 10 2008
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA.- DEPARTMENT OF HEALTH AND H
<br />202205736
<br />id
<br />1.19ECEDL°NT'8•NAME (First, Middle, Last. Suffix)
<br />Donald Herman Muhs
<br />.:+w �� i
<br />i 482
<br />t CRY AND STATE OR TERRITORY, OR POREIGN COUNTRY OF BIRTH
<br />ea. AGE•Lest Birthday
<br />6b. UNDER 1 YEAR
<br />6c. VN R 1
<br />OF f l0y oayiYW)' . ;
<br />Hall County, Nebraska
<br />(Yrs.)
<br />75
<br />MOS:
<br />DAYS
<br />HOURS
<br />,IAINB,
<br />Jaiiary 7,1 •
<br />7. SOCIAL SECURITY NUMBER
<br />8a. PLACE OF DEA -RI
<br />HOSPITAL; II Inpatfe5t Coning Homdl. O ba daabll
<br />To Be CompletedNerifled by: FUNERACTRIIECU
<br />- Eb. PROILITY-HAMS fif red hsfb16dn, Sive street and number)
<br />Saint Francis Medical Center
<br />0 "P1 © gym'! 1 e•
<br />.. _
<br />0 DOA Q OtherNPecity)
<br />sir
<br />1fe. CITY OR TOWN OF DEATH (include Zip Code)
<br />`Grand island 88803
<br />&L COUNTY OF DEATH.
<br />Hall
<br />9a. 1SSIDENCE•BTATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />i,•
<br />8c. CITY OR TOWN
<br />Grand Island Y
<br />A
<br />9d. STREET AND NUMBER
<br />254 South Plum
<br />9e. APT. NO.
<br />8C ZIP CGDE
<br />68801•
<br />9 .t
<br />:8¢1NB4efYt$1Ta'`
<br />Yes. No.. '
<br />tOa. MARITAL STATUS AT TIME OF DEATH ® Maned ❑ Never Marded
<br />O Minted, but separated Q Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (FirstMeddle. Last, SMe101fwaa.)pw r d88 name .' 1
<br />Dolores ,Eleanor Stefanowtoz
<br />11. FATHER'S41AME (First, Middle, Last, Suffix)
<br />Herman Mohs
<br />t
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname) ...
<br />Hilda Reher
<br />19. EVER IN U.S. ARMED FORCES? Give dates of service (rtes.
<br />(Y011.No orUnk.) Yes 02/11/1953-02/10/1955
<br />14e. INFORMANT.NAME
<br />Dolores Muhe
<br />14h. RELATIONSHIP $ DBDEDE+IT
<br />Spouse.
<br />15. METHOD OF DISPOSIITON
<br />®Burial Donation
<br />18a EMBALM GNA/URE
<br />,, /AA LAD �,�,.(
<br />15b LICEN NO.
<br />/39 ?.
<br />7� DATE (Me .Det. 7K)
<br />September 20011
<br />Qcraiagon Qnnaahbaeni
<br />Q Q a
<br />�
<br />16d EME . CREMATORY OROTHER LOCATION
<br />Westlawn Memorial Park
<br />..
<br />crearOWN
<br />Grand Island -
<br />,
<br />.. �t ,,...,.i ..,
<br />4 A' ;
<br />Nebraska
<br />171. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Cit+ or Town, Stare) ... -
<br />Alt Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />`17b.210 `17b. TIP Codas''. ' '
<br />81801 -
<br />,
<br />To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH 'Mee instruction and exalnples�'.
<br />1e.PMT1.miter the •divasa.In)uaes.orecalplbationathatdlnedymwdtin4..01 D0Notenterbrmtalevaet4erehuau,Luarpq:' 1 APPICIMATLli1I3'ERVAL
<br />wspkteuryarn,t. er fWIIWlonwaWuteeawbg WeWolagy. tw NOTAEEREwATE anter enb ee. wuee one Wha.Md Waaarellata 6eeuewtr.
<br />IMMEDIATE CAUSE:- • ...' onsetto d ath
<br />IMMEDIATE CAUSE (Fina e11e (l. (/1,.1 a h 14
<br />disease or ao Millon reaulting a) I " .Y'ML, # f -.
<br />in death)
<br />i
<br />i 1 ." , ;
<br />DUE TO, OR AS A CONSEQUENCE OF: 0nset30 death ;
<br />I
<br />SequenUalty Use eondlfone, It 1 a1
<br />any, leading to the cause listed bj Y v �U'•' " Q a.(n f►� 1
<br />on Me a. DUE TO, OR AS A CONSEQUENCE OF: onset to dead.
<br />1
<br />Enter the UNDERLYING CAUSE c) 1 -" - -
<br />Initiated
<br />(disease or Injury that 1,...-. 1immir-«.
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:onset to death
<br />I LAST
<br />I
<br />d)
<br />18. PART it OTHER SIGNIFICANT CONDITIONS.Cotdltou contributing to the death but not resulting In the u.dedylng carn:glverin PANT L .
<br />n_
<br />eeq (1C I n So h `,5 ( fit' Yt'9 e, P-06%,
<br />19: WMBIYIIIDiCA.BXAIRPI
<br />OR CORONER CONTACTED?
<br />O. Yes. Miro
<br />20. IF FEMALE:
<br />❑Not pregnant within past year
<br />21e. MANNER OF DEATH
<br />(kliatural 0 Homicide
<br />TRPORTA/ION INJURY
<br />21b. IPANB
<br />❑ Ddv r/Operator
<br />'
<br />21c. WAS AN AUTOPSY PERP9RAlED?
<br />0 YES Elan .
<br />Q Pregnant at time of death
<br />❑Not pregnant, but pregnant within 42 days of death
<br />❑Net pregnant, but pregnant 43 days to 1 year before death
<br />❑Unknown If pregnant within the past year
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />Q Passenger
<br />0 Peduklen. -
<br />0 Other (Specify)
<br />21d, WERE AU OPSY PMAIRGB ttAiCA1LE
<br />TO COMPtt?7te DF TRAM? _.
<br />0 Yes 0 f . -•
<br />14
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF ILNRY•At honnk farm, street, factory. officio bmWing.anuetrucUcn site, eta (Spselfy)
<br />22d. INJURY AT WORK? '
<br />❑YES ❑NO
<br />22e. DESCRIBE HOW INJURY OCCURRED '�
<br />Ii
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT, NO. CITY/TOWN STATE ' ZIP cone " '.
<br />Zi
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 28, 2008
<br />A'I
<br />1
<br />21a. DATE MGM (Mo., Dry, Yr.) '
<br />24b. TIME OF DEATH .•
<br />m
<br />11 }
<br />Rg2-Zaar;
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />230. TIME 0P DEATH
<br />2:30 p m
<br />Y
<br /><i
<br />210. PRONOUNCED DEAD (Mo., Day. Yr.)
<br />YNR. TIME PRONOANOSDI:EAD
<br />m
<br />gg
<br />3 -
<br />oand
<br />1
<br />23d. To the best of my knowledge, • -;, occrred at the time, date and place
<br />due s) uta . nature and Title)
<br />11
<br />W/
<br />IT z
<br />c m
<br />t)t
<br />244. On the basis of exmdnaUot andlor hwreatlgatton, In ovy opinioe death.
<br />at the time, date andptace and due to tie eausefs) dated. isewire er)1 T11
<br />26. DID TOBACCO UBE CONTRIBUTE TO THE , ., TN?
<br />o YES titNO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES pcno
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable 120. Is NO 0 YE$ $ No
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Gary Settje M.D., 2116 W. Faidley Ave., Grand Island,
<br />Nebraska 6.88Q3 ..
<br />28a. REGISTRAR'S SI3NATURE
<br />P
<br />18b DAT! FILED EY mamma (Mo; yr.
<br />SEP 9 2008
<br />
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