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<br />STATE OF NEBRASKA
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<br />WIZEN MIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBAASK4 DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OFISSUANCE
<br />1 U/�12t1�3 '
<br />LINCOLN, NEBRASKA
<br />202305652
<br />SARAH BOIINENKCAMP`
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />11 DECEDENT$ NAME (First, Middle, Last, Suffix)
<br />ll Qwefi• DeklRay Lemburg
<br />r4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Wood River, Nebraska
<br />7 SICIAL SECURITY NUMBER
<br />507..56-2304
<br />8b: •FACILITY tAlME (Brio! Institution, give street and number)
<br />I CHI Health St, Francis
<br />8c.Fil ¢R TI wN QF DEATH;(Include Zip Code)
<br />' Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d .STREET ANp NUMBER
<br />603 W 6th Street
<br />Sa AGE Last Birthday
<br />(Yrs.)
<br />72.
<br />6b UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 3 tttpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9b. COUNTY
<br />Hall
<br />10a.. MARITAL STATUSAT TIME OF DEATH 0 Married 0 Never Married
<br />Married, but separated ria Widowed ❑ Divorced ❑ Unknown
<br />$ u
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Carson Lembuz
<br />I. 13.. EVER IN US. ARMED FORCES? Give dates of service If Yea.
<br />S (Yes, No, or Unit.) Yes 03/30/1966-03/11/1968
<br />15. METHOD OF DISPOSITION
<br />a d Burial ( porta ion
<br />Crematigtl [ Entombment
<br />Removal [] Qther (Specify)
<br />u
<br />9c. CITY OR TOWN
<br />Doniphan
<br />HOURS
<br />MINS.
<br />19 04771
<br />3. DATE OF DEATH it4o,i08y YR)
<br />March 302011
<br />6. DATE OF BIRTH (Mo., D*j r.)
<br />January 14, 1947
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68832
<br />os)fice Fa pity
<br />TOD. NAME QF SPOUSE (Fir Middle, Last, Suffix) If wife, give madden
<br />Twila Dierkinp'
<br />l12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Charlotte ! Buswell
<br />14a. INFORMANT -NAME
<br />Keith Lemburq
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Heafey-Hoffman-Dworak-Cutler
<br />17a FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Wel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Omaha
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART!. Enter the chain of events diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />ID MISDATE CAUSE (Flildi a)Anoxic Brain Injury
<br />Ithat.. of foddgw, resenting
<br />w
<br />deetiS
<br />A Sequentially list, conditions, If.,
<br />ae any, reading to the cause listed
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Cardiac Arrest
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYINO CAME 0)
<br />(disei80 or injury that initiated
<br />1
<br />the events resulting M death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />9g INSIDECITYUMFis:
<br />YEB I <NO
<br />14b. RELATIONSHIP TO DEGN'f'
<br />Son
<br />•
<br />April 4, 2D"I9 ..
<br />STATE
<br />Nebraska
<br />17b. 2/p :C0d9 :
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset tq death
<br />Days
<br />18. PARTE.' OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />ChMIC Obstructive Pulmonary; Disease
<br />io 20. IF FEMALE:
<br />NMluxuriant within past year
<br />Pregnantat ghee of death
<br />Not pregrant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown if pregnant within the. past year
<br />Q
<br />22a,DATEDF!NJURY(M0 Day,Yr.);
<br />g 22d. INJURY AT WORT
<br />'0 ❑ YES ❑ NO
<br />21a. MANNER OF HomDEATH
<br />Natural uida
<br />El
<br />❑ Accident 0 Pending Invesdgation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />214. IF TRANSPORTATION INJURY
<br />•1:1.5#7/Operator
<br />'❑ Passenger
<br />Peeestria
<br />0 Other (Specify)
<br />onset to death
<br />19. WAS MEDICAL: EXAMINER
<br />OR COERCONTACTED7•
<br />❑ YEB,RQNE NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES E Flo
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑,YES NO
<br />22c. PLACE OF INJURY.At home farm, street, factory, office building, construction
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />". i22f (OCA.TiON OF INJURY STREET& NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo.,' Day, Yr.)
<br />March 30 2019
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Abtil 1.2019
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />11:36 AM
<br />234. To Lire best of nY knowledge, death occurred at the time, date and place
<br />anti dues tq the tause(s) stated. (Signature and Title)
<br />Chid Vieth. MD'
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES NO 0 PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />(SpeciN)'
<br />ZIPOODE
<br />24d. TIME PRONOUNCED DEAD
<br />34e. Cn pre heals of examination and/or investigation, In my opinion death gCCtirrad al
<br /><tlta time; date and place and due to the cause(s) stated. (Signature pill# rifle).
<br />26a. HAS ORGAN QR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ENO
<br />27. NAME, TIT( AND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD,2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO 13813
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 16, 2019
<br />
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