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°Ali Distil
<br />11/12t2IZ4'.
<br />LINCOLNr'NN$BRAS M.4,
<br />1':•DECEOENT, S
<br />uS(nd• '
<br />4, CITY AND STA
<br />Ni3bra
<br />Ill 1 1 \\ . Cth45r..,Ntos>::. ,z%'r,( nr t\N.. y iv
<br />Jllllhu,.`:._' ...... bul'I'1:1'Prtiu:...._",.uNuDst
<br />STATE OF NEBRASKA
<br />7,rmm,,,t\\,y'•a,za4c4rr,rl�ee�.,
<br />A/SED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO'' ,
<br />RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />2G25O126►6
<br />'7
<br />)6z, hff non it 7k4•f
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRA
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />ast, Suffix)
<br />REIGN COUNTRY OF BIRTH
<br />8b. FACJLITY•NAME (If taot' In1t,Nhetioit a lire street and number)
<br />Tabitlla:at Prair€e`lamimahs
<br />I.TY CtR'TQ>WN; b
<br />ra'ndIsla
<br />nd '€
<br />11.:FATHER'$KNAMI
<br />J EVER rN U.$, Ail
<br />.(Yes, No, orUrik.j
<br />DEAl'li In de Zip Code)
<br />9b.000NTY
<br />Hall
<br />ftME 01 DEATH ® Married 0 NeverMarried
<br />Vidtwsd ❑ Divorced 0 Unknown
<br />e, Last, Suffix)
<br />FOftCE$P; t#ivs dates of service if Yes.
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />81
<br />6b. UNDER 1 YEAR
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Female
<br />5c. UNDER x'DAY
<br />HOURS
<br />DATE
<br />N:ts►O., X; Yr
<br />O0tob'$'..24
<br />OTHER 0 Nursing Home/LTC'
<br />0 Decedent's Home
<br />E Other pecily%
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, givema
<br />Lonnie Husing
<br />14a. INFORMANT -NAME
<br />Lonnie Husing
<br />1N, EMBALMER•SIGNATURE
<br />Not Embalmed
<br />1VS4. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremahion Services
<br />Via. FuNE!4i t3fiN4i*NANtE'AR LING ADDRESS (Street, City or Town, State)
<br />All. aitI1S„Fui eral Hof
<br />. Locust Street, Grand Island, Nebraska
<br />MOTHER'S -NAME (First, Middle, Malden
<br />Lydia Siefken
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />cries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />:bout showing the etiology. DO NOT ABBREVIATE, Enter onty one cause on it line. Add additional Imes if necessary.
<br />iMMi✓b(ATE CAUSE:1 •
<br />A} tleimer's dementia
<br />I 1 �
<br />OR AS A CONSEQUENCE OF:
<br />sgtrittttatty h$ t a�rdi 1cns 'lt.:.., b1
<br />hY +ainq`ta M±tciva itY)att
<br />ertt sJNtfERL.tP4 CA{,tut
<br />r. tO tNurytht1k;atd'
<br />etantt n}Wtin9,9ittNtttl)
<br />l.T
<br />ART:It<Q; I E:SOh1IFl
<br />kniif tte
<br />l9^anL b4t p gnarl
<br />Ohs nt l pr/ am n143 klays tt
<br />tfbwn li t±riignset rrlthiii iTit:#lt,rist'
<br />A
<br />Y
<br />Y)
<br />2rATtQN.:0001JU;I y.rS
<br />t1t
<br />YE
<br />0
<br />24
<br />brUATE.SIONEot f t
<br />• Ploverrri •-r
<br />cro.t/ae ii��i +irint�
<br />••:•iti i 47ti¢':ia ttftR.'Ee
<br />A C0:
<br />AMrc,;ftl E AHl3 At
<br />D.Crouch.D
<br />A
<br />iI
<br />4,
<br />A CONSEQUENCE OF:
<br />A CONSEQUENCE OF:
<br />NS-Conditions contributing to the death but n
<br />ath
<br />21a. MANNER OF DEATH
<br />Natural ❑ Hemysids
<br />Accidem ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />resulting in the underlying cause given In PA
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJU
<br />E HOW INJURY OCCURRED
<br />TH
<br />BER, APT.NO.
<br />CITY/TOWN
<br />23c, TIME OF DEATH
<br />64:03 PM
<br />ccurrea at the time, date and place
<br />and Tale)
<br />ATH?
<br />❑:.PRciimaLY 0 UNKNOWN
<br />1 k5S OF OiRtiPIER (Type or Print
<br />Ewoldt St, Grand Island, Nebraska, 68803
<br />rA
<br />lb. IFTRANSPORTATION INJURY
<br />❑ Orwer/Operator
<br />0 Pamenger
<br />❑ Pedestrian
<br />9 Other(Specify)
<br />T1.
<br />21c. WAS AN
<br />0 YES,.
<br />21 d. W
<br />TO Cl
<br />❑ YES
<br />oms, farm, street, factory, office building, coast
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b.
<br />2 the heals of examination and/or Investigation, Wolff
<br />the tinie, date and place ancl due to the cactee(e) shoed. (
<br />26a. HAS ORGAN OR tiSsue bowl
<br />YES NO
<br />tl 464%1—-/7.-t7�+
<br />PERE
<br />BEEN CONSIDERED?
<br />26b. WAS CON
<br />Not Applicable If 26s le NO
<br />
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