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<br /> „ . Reg.Dist No. VIT�I STATISTICS � . ,
<br /> �,,,�„��N � Primery Reg.Dist No. CERTIFICATE OF DEATH Stete File No.
<br /> NES°��0DH � TYPE OR PRINT IN PERMANENT BLACK INK
<br /> 011TACODIN6 Registrar's No.
<br /> 1. eCedenYS Nam¢fFirst Middle,1AS71 2.Sex 3.Date Of eB[h/Month,Oey,Yeer)
<br /> °� Harry Martens Male December 16, 1998
<br /> b• 4.Sociel ecurity Number 5a.Age-Lest Birthday 5b.Under One Year 5c.Under 1 Da &Date ot Birth lMonm,Day,reerl 7.Birthplace ICiry+ndSrmor!»mpntoun�l
<br /> � lYeersl Months Deys Hours Minutes
<br /> d 508-18-5626 80 Oct. 19, 1918 Hall County, NE
<br /> e.
<br /> 8.Was Decedent Ever in U.S.Armed Forces7 ge.Plece of Deeth lCheck OnlyOne)
<br /> Hospitel � Other
<br /> i�.Yes $No (�Inpatient U EWOutpatient [DOA ❑Nursing Home L;Residence �`Other ISpeciryl
<br /> � 9b.Faciliry Name (IlNorinsrirurion,Give SnsereneNumber/ 9c.City,Village,Twp.,or Location of Death 9d.County of Death
<br /> St. John West Shore Hospital Middleburg Heights Cuyahoga
<br /> 10.Marital Status•Memee,NeverMerried, 11.Surviving Spouse Itl Wife, 12e.DecedenYs Usual Occupation IGive kind o/work done 12b.Kind ot Business/Industry
<br /> Wdar�d.Diwced fSpeedY) GivaMeidenNeme) durinpmosro/workinpli/e.Donotusefletired) American Crystal �
<br /> 10F1TX0� Married Helen En el Assistant Superintendant Sugar Company
<br /> w.amunow.arvE
<br /> �eaoe�e�ra� 13a.Residance-State 13b.County 13c.City,Town,Twp.,or Location 13d.Street and Number
<br /> �� �
<br /> NE Hall Grand Island 1023 East Oklahoma
<br /> 13e.In:;ide City limits7 13f.ZIP Code 14.Wzs Decedent of Hispanic Oriqin7 �Yes �No 15.Raca-Amerieen�ndian,Blstk, 18.�ecedenYs Educetion G���Lum,^�sr a1��
<br /> (Il Yes,Sp�ci/yCubsn,Hlexican,Puerto Ricen,etc.J �ite,e[c.(Specily) Elert+entery/ econdery 0-12 otlepe 1-4 or 5r
<br /> �ves �No 68801 White 12
<br /> 17. ethe S ertlB(Firat Middle,UaU 18.MOthers Name(Frrs�Midd/e,MeiEen Surneme)
<br /> ��� Otto Martens Leona Scheel
<br /> 19a.InformanYsName/TypyPrlrrcl 19b.Metlinp dress/SrreetendNumberorRu�alRoureNumber,CiryorTown,Srare,ZlpCoael
<br /> 1' �
<br /> Helen Martens 1023 East Oklahoma, Grand Island, Ne 68801
<br /> a. ethod o isposition 20b, lace of isposition fNsmeolCemstery Cnmarory, 20c.Location CiNorTown,Stsre
<br /> �lBuriel -.Cremetion orOtherPlacel
<br /> �Removal from State
<br /> _no�,00� `p�erlsa��Nl Westlawn Cemetery Grand Island, Nebraska
<br /> 20d.Dete oi Disposition 21e.Name of Embalmer 21b.License Number
<br /> � �� � December 21, 1998 Paul J. Sobczyk 7386A
<br /> 22a.Signature of Funeral Dir Other Person 2Zb.License Number Io�Licensee/ 23.Name end Address of Faciliry
<br /> 6670 Robert P. Smith Mortuary Service, Inc.
<br /> 4. e s ignatura 25.Dete �iediMo�n�,Dsy,Yeer) 4701 Hinckley Industrial Parkway
<br /> 3 � Cleveland, Ohio 44109-6098
<br /> 26 i ture of Person Is ' g Per it ' a 26b.Dis�.No.- 27.Date Permit Issued
<br /> f. � Q
<br /> a• 28e.Certifier -Csrti m Ph ician
<br /> ICheck Onl One/ �• B �
<br /> � To the bart of my knowledpe,death occurred at the ume,date,end plece;end due w the ceusels)and menner es stated.
<br /> _ ,,,r:. ----------------------------------------------------
<br /> i
<br /> $Coronsr
<br /> On ihe besis ot eaemination end/or investigetion,in my opinion,deeth occurred at the time,dete,and plece;end due to the cause�sl and menner as r�teted.
<br /> 28b.Time of eeth 28c.Dete Pronounced Dead /Monrn,Day,Yesd 28d.Was Case Referred to Coroner?
<br /> i 3:30 A. M Jecembei� 16, 1998 �'veS - No
<br /> k- 28e.Signature and Title of Certifier 28f.License Number 28g.Date Signed (Monfh,Day,Yeerl
<br /> � > - M.D. Coroner 034779 December 22, 1998
<br /> m . ame end d ress o erson who omp eted ause eath (Type/Prinrl
<br /> "' Elizabeth K. Balra' M.D. Coroner 2121 Adelbert Road Cleveland Ohio 44106
<br /> °• 30.PeR I. Enter the diseases,injuriea,or complicetlons thet caused the death.Do not enter the mode of dying,such as cardiac or respiratory arrest, Approximete Intervel Benveen
<br /> P•
<br /> shock,or heart failure.List onlv one cause on eaeh line.Tvpe or print in psrmenent bleck ink. �onse�and Dee�n
<br /> Immsdi�te C�use a
<br /> 4• I
<br /> �Finafdiseeseorcnndition � pending. �
<br /> � resuMnp in JeaM)
<br /> b.Due to Ior es e Consequence of) I
<br /> °' Saquemi�lp list conditions, I
<br /> t if eiry,leedinp to the immediete -
<br /> cause. c.Due to lor as e Consequence oi) �
<br /> � Emer Undsdrinp Guss Lest
<br /> I
<br /> lDiseese or injury that initiaMd �-._
<br /> rvents resuninp in desrnl d.Due to lor as a Consequence ofl
<br /> I
<br /> � I
<br /> � ------ ---- ---..._._------.__.. __
<br /> Part II.Othersigni(icant condi6ons contributing to death but not resulting in the underlying cause given in Part I. 31 a.Was an Autopsy 31b.Were Autopsy Find�ngs
<br /> SEEINSiBUCT10N5� PB�O�med^ A��a�•�.;,t�c F;;o�ic.Cun,p,r.�r.
<br /> ONNEVEIISESIDE OI CAlISC 0�DBB�h�
<br /> $Yes No Yes 1�No
<br /> ennsr ee 33�. ete o n ury 33b.Time f n�ury 33c.In ury et Wark7 33d.Describe How Injury ccurred
<br /> �N�Nrd �Peodinq /MoMh,Diy,Ysul � M -Yes �No
<br /> `�e�� Inwstipetion - -
<br /> HEA2717 33e.Plaee of Injury•lu�,hr�Sval,hetary,0lfiuBu�d'inp,kc. ISperyl 33}.LOCetion(Street end Number or Rurel Route Numbar,City or Town,Statel
<br /> -Suitida -Could NM ba
<br /> 51`.�-O6 pe�•�9/ - Determined
<br /> .-Homicida
<br /> �
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<br /> �Ev�,h1 HWwOr� F i('I�03,+�;,�In�T�,�,_:.�d c..r._ .HA..._>_� � f� �' 4�
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<br /> CE� � T1 FI ED� � �..`,, ,
<br /> 1 HEREBY CERTIFY THAT THIS 1S"i�N ,�,
<br /> pCACT COPY OF THE RECORD WH_ICH ' ' `�-
<br /> IS ON FILE IN THE OEPARtMENT OF
<br /> " HEALTH,�CLEVELAND, OHIO • : � ;,r. �
<br /> � � o�� :FEB - 21999 ����� � �, �� �� . .�:�
<br /> j _
<br /> .
<br /> lOIiTRAR
<br /> VYITN HAND AND SEAL AS .
<br /> LOCAL REGISTRAR OF VITAL STATISTICS
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