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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />SYSTEM, IT CERTIFIES THE BELOW TO BEA TRUE COPY OF Ma
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, V
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF,ISSUANCE
<br />MAY 2 3 2005
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES F,NANCEA1VtSUPPORT
<br />ne
<br />RTIFICATE OF DEATH
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Dixie June Obermeier
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day,Yr.)
<br />April 22, 2005
<br />1 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE -Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />Mullen, NE
<br />(Yrs.)
<br />65
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />November 14, 1939
<br />``
<br />7. SOCIAL SECURITY NUMBER
<br />506-50-1750
<br />8a. PLACE OF DEATH
<br />ji0SPITAL: 0 Inpatient Sate 7ClNursing Home/LTC UHosptehacittty
<br />8b. FACILITY -NAME (If not institution, give street and number)
<br />Madonna Rehabilitation Center
<br />0 ER/Outpalent 0 Decedent's Home
<br />❑ cm 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Lincoln 68506
<br />8d. COUNTY OF DEATH
<br />Lancaster
<br />9a.RESIDENCE-STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1008 West Anna Street
<br />9e. APT. NO
<br />91. ZIP CODE
<br />68801
<br />9g. INSIDE CITY UMITS
<br />YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 32MarrIed 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Joseph Obermeier
<br />11. FATHER'S -NAME (First, Middle, Lest, Suffix)
<br />Jesse James Ingrumv
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Helen Hazel Christman
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If yes.
<br />(Yes, no, or unk.) No
<br />145. INFORMANT -NAME
<br />Jose.. Obermeier
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />15. METHOD OF DISPOSITION
<br />NI Burial ODonation
<br />16a. EMBiit;.SIGNATUR
<br />/........"., �,:
<br />_w51 -
<br />16b. LICENSE NO/0 2
<br />3
<br />18c. DATE (Mo., Day, Yr. )
<br />April 27, 2005.
<br />0 Cremation 0 Entombment
<br />0 Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY e j ER LOCATION CITY / TOWN STATE
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska:
<br />17a. FUNERAL HOME NAME AND MAIL NG ADDIIIESS (Street, City or Town, State)
<br />All:Faiths Funeral Home 2929 S. Locust St., Grand Island, NE
<br />'Sw
<br />18. PART I. Enter the chain of events -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE
<br />17b. Zip Code
<br />68801
<br />INTERVAL
<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. 1
<br />° IMMEDIATE CAUSE: onset to death
<br />1 " u t R
<br />" IMMEDIATE CAUSE (Final (a) '� N a�v� F' c ► (
<br />#
<br />r
<br />" I
<br />diseaseorcondllon resulting DUE TO, OR AS A CONSEQUENCE OF: i onset to death
<br />indeath)
<br />Sequentially flat conditions, if (b)P {n V'Q 1%A,'\g't/1 \q RECEIVED
<br />any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />on line a. JUN
<br />Enter lheUNDERLYINGCAUSE V V fv O 32005
<br />(disease or Injury that Initiated (o) - it J _ r
<br />the events resulting In death) DUE TO, OR ASACONSEQUENCEOF: I onset to death
<br />LIQCLAIMS
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Y (} `
<br />\ IZ Nclwl'er- s
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES GxNO
<br />J ?
<br />20. IF FEMALE:
<br />I$ Not pregnant within past year
<br />21a. MANNER OF DEATH
<br />�4.1Jatural 0 Homicide
<br />0 Accident0 Pending Investigatlon
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES atm
<br />0 Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days 101 year before death
<br />0 Suicide ❑Could not be determined
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />0 VES 0 NO
<br />0 Unknown If pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction elle, etc. (Specify)
<br />v'e
<br />22d. INJURY AT WORK?
<br />0 YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) -
<br />April 22, 2005
<br />as
<br />.115
<br />245. DATE SIGNED (Mo., Day, Yr.)
<br />24b.TIME OF DEATH
<br />m
<br />�
<br />11
<br />1r. E13
<br />28 (2005 Yr.)
<br />Aprilb. DATE SIGNED
<br />23c. TIME OF
<br />6 s 00P E DEATH
<br />m
<br />j24c.
<br />PRONOUNCED DEAD (Mo., Day,Yr.)
<br />24d. TIME PRONOUNCED DEADm
<br />fe
<br />000
<br />1-a
<br />23d. To the best of
<br />and due to
<br />r
<br />my knowledge, death occur
<br />h ause slated. (Signature
<br />1
<br />ed at the time, date and place
<br />and Title) ♦
<br />LI -22. '0 5
<br />8 tris E '
<br />I oo cool
<br />8S
<br />24e. On the basis of examination and/or Investigation, In my opinion death occurred et
<br />the time, date and place and due to the cause(s) stated. (Signature and Tile) •
<br />°
<br />25.DIDTOBA000
<br />0
<br />USE CONTRIBUTE T T EATH?
<br />YES it NO 0 PROBABLY 0 UNKNOWN
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES 260
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable It 26a Is NO 0 YES Lir
<br />'• ' " pq
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Daniel B. Einspahr, M.D. 3901 Pine Lake Road, Suite 220, Lincoln, NE 68516
<br />28a.REGISTRAR'S SKiNATURE�� /1.
<br />YYI)V//►LNIi.✓1A�J
<br />28b.DATEFILEDBYREGISTRAR (Mo.,Day, Yr.)
<br />APR282005
<br />
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