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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA.' <br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE JAN IGr <br />LINCOLN, NEBRASKA <br />002 Oft <br />HEALTH - I + SERWO TEA1 <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND H U! RWGEf Ficirthro SUPPORT <br />VITAL STATISTICSs- <br />CERTIFICATE OF DEATH ' x 2 gJr c <br />202304731 <br />I. DECEDENT • NAME FIRST MIDDLE LAST <br />Hobart Emil Lemburg <br />"2. SEX 4 , <br />Male <br />3. DATE OF DEATH (Month. Day Year) <br />January 11, 2002 <br />4. CITY AND STATE OF BIRTH III not in U.S.A. name country! <br />5a AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH (Month. Day Year) <br />Wood River, Nebraska <br />(Yrs.)56 <br />5b. MOS. I DAYS <br />Sc. HOURS <br />August 11, 1945 <br />7. SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH <br />HOSPITAL ❑ Inpatient OTHER: E Nursing Home <br />508-54-4639 <br />8b. FACILITYIT• Name (Ii not institution. give street and number) <br />❑ ER Outpatient ❑ Residence <br />❑ DOA ❑ Omer (Spenly <br />Lakeview Nursing Home <br />. <br />BC. CITY TOWN OR LOCATION OF. DEATH <br />Grand IslandYes <br />6d. NSIDE CITY LIMITS <br />J No ❑ <br />8e. COUNTY OF DEATH. <br />Hall <br />9a. RESIDENCE - STATE <br />Nebraska <br />911 COUNTY <br />Hall <br />9c CITY. TOWN OR LOCATION <br />Alda <br />9d. STREET AND NUMBER (Including Zip Code) <br />41 Blue Jay 68810 <br />9e. INSIDE <br />Yea <br />CITY <br />LIMITS <br />No ❑ <br />10 RACE - (e.g., While. Black. American Indian. <br />elc.I sLwhite <br />11. ANCESTRY le.g. Italian. Mexican. German, etc) <br />Isaea l German <br />12. <br />(: Ir <br />❑BBI <br />MARRIED ❑ WIDOWED <br />NEVER El DIVORCED <br />MAED <br />13. NAME OF SPOUSE la mile give maiden name) <br />Karla Gartin <br />14a USUAL OCCUPATION (Give kind of work done during most <br />of working Ale. even if refired! <br />Truck Driver <br />14b. KIND OF BUSINESS INDUSTRY <br />Transportation <br />15. EDUCATION (Speedy only aghast grade Completed) <br />Elementary or Secondary 10.121 College 11.4 or 5- , <br />7 <br />16 FATHER - NAME FIRST MIDDLE LAST <br />Carson Lemburg <br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Charlotte Buswell <br />18. WAS DECEASED <br />(Yes.NO or unk.) <br />EVER IN U.S. ARMED FORCES? <br />I 111 yes. give war and dates of services) <br />N/A <br />19a. INFORMANT - NAME <br />Karla Lemburq <br />19b. INFORMANT MAILING ADDRESS I STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) <br />41 Blue Jay Alda, Nebraska 68810 <br />20 EMBALMER - ` NATUR LICENSE NO. <br />/Z r' <br />22a. FUNERAL HOME . NAME <br />Apfel Funeral Home <br />21a METHOD OF DEPOSITION <br />® Burial ❑ Removal <br />❑ Cremation ❑ Donato. <br />216 DATE <br />1/15/2002 <br />21c. CEMETERY OR CREMATORY NAME <br />Wood River Cemetery <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Wood River, Nebraska <br />2213. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, 21P) <br />411 West 11th Wood River, Nebraska 68883 <br />23 <br />IMMEDIATE CA (ENTER (LY ONE CAUSE PER LINE FOR la(bl. AND (c)) <br />PART 2�J-7�j () y <br />DUE TO, OR AS A CONSF/`7�OUENCE OF <br />('GG (/fixtE G- inti <br />Interval between onset and death <br />(b) cittYaL 1. <br />DUE TO. OR AS AONSEOUENCE OF: <br />,45 <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related <br />PART <br />• <br />Interval between onset and death <br />Interval beln onset and death <br />/ /S <br />PART BI IF FEMALE WAS THERE A <br />PREGNANCY IN THE PAST 3 MONTHS? <br />(Ages 10-54) Yes ❑ No ❑ <br />24. AUTOPSY <br />Yes ❑ No ELI <br />25. WAS CASE ERRED TO MEDICAL <br />EXAMINER R CORONER? / <br />Yea <br />No <br />26a. <br />Accident a Undetermined <br />Suicide El Pending <br />IDHomicide Investigation <br />27a. D T DEATH (Ma. Day. Yr.) <br />/fit 4-12/ !/, <br />27b. OA SIGNED (Mo.. Day. Yr.) <br />26b. DATE OF INJURY (Mo.. Day. Yr.) <br />26c. HOUR OF INJURY <br />M <br />28d. DESCRIBE HOW INJURY OCCURRED <br />26e. INJURY AT WORK <br />Yes ❑ No ❑ <br />261. ic ebur Fns eeNRY -4tfw.mr, farm. street. factory <br />28g. LOCATION STREET OR R.F.D. NO. <br />CITY OR TOWN <br />STATE <br />9*), 1, / J <br />27d. To the best of my knowledg <br />causelsl stated." <br />(Signature and Title) ► <br />002_ <br />27c. TIME OF DEATH <br />23 <br />them date anII4lE e6nd due to the <br />S ORGAk OR TISSUE DONATION BEEN CONSIDERED? <br />❑ YES NO <br />29. OID TOBAC 0 USE CONTRIBUTE TO THE DEXTRO <br />YES Li NO ❑ UNKNOWN <br />M <br />28a. DATE SIGNED (Mo. Day. Yr.I <br />izy/sl 42 <br />ONOUNCED DEAD (Mo.. Day, Yr./ <br />28b. TIME OF DEATH <br />28d. PRONOUNCED DEAD lHourl <br />28e, On the basis of examination and/or investigaaon, in my opinion death occurred at <br />00, the time, date and place and due to the causels stated <br />(Signature and Tele) le <br />M <br />M <br />30.b WAS CONSENT GRANTED? <br />❑ YES NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEYI (Type or Print) <br />William Lawton, MD <br />32a. REGISTRAR <br />2444 st Fat - Ave. <br />Grand Island, NE 68803 <br />32b. DATE FILED BY REGISTRAR (Ma. Day. Yr.) <br />JAN 17 2002 <br />