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Ei
<br />CERTIFfES' :THE
<br />ON FILE WITH
<br />f RECORDS OFFICE;
<br />DATE OFISSUANCE
<br />9 0/3i2019
<br />STATE OF NEBRASKA >,
<br />a.fin,lbsc>�•-.:.•u2�9TI'I'I'1�11111 >S.>•.,. ,,'a.2.rih'f�ll.�a.-•:.•<i:7J'I'1:I:I�P.11il:�ga>..::
<br />CARRIES THE RAISED SEAL OF..: THE STATE
<br />DOCUMENT BELOW TO BE A TRUE COPY OF TK
<br />THE NEBRASKA DEPARTMENT OF HEALTH AND HU
<br />WHICH IS THE LEGAL DEPOSITORY FOR VITAL .RECORDS
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPAR NT OF HEALTH.
<br />AND�UMMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HU SERVICES
<br />CERTIFICATE OF DEATH
<br />202600157
<br />DECEDENTS NAME'(I rst Middle, Last, Suffix)
<br />Carol Barbara Albertuis
<br />4. CITY AND STA1E OR TERRrrORY, OR
<br />Eminence,Missl>uri
<br />7. SOCIAL SECU 7Y NUMBER
<br />RI
<br />498.38-9032
<br />.FAOtI UA N ►ME;(W not Ineti
<br />S. CI
<br />9d. STREET ;NO NUMBER
<br />1629 St Paul Road
<br />ioa MARITAL STATUSAT TIME
<br />❑:Marrtad,butaepaetad
<br />N
<br />and number)
<br />lib. COUNTY
<br />Hall
<br />OF BIRTH
<br />EATH Q Married 0 Never Married
<br />Widowed 0 Divorced 0 Unknown
<br />')i. Fl1#Fi'ER's�NAME. {Fired,
<br />tveron; Warren
<br />RtN U.S..ARMED PORCE
<br />(*as, NQ::or UN*.)NQ .. :
<br />15-M000 OF DISPL>SOM5M
<br />9urial 13 Coniston,.
<br />Cremotion. 0 Entombment
<br />� #ttf>it • al °,,.17,0th01lSOICRY)
<br />Middle,, Last,
<br />Suffix)
<br />Give dates of seavkm If Yes.
<br />5a. AGE - Lead Birthday
<br />(YM.)
<br />82
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />NOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />0.ER/Outpatient
<br />© 00A
<br />I c. CITY OR TOWN
<br />Grand lsl/nd
<br />HOURS
<br />MINE.
<br />3. DA'
<br />Sean►ber 7,
<br />OTHER 0 Nursing HomslLTC
<br />® Decedent's
<br />Dom(
<br />�Ft
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, gam•
<br />• Noel Albertus
<br />1 1Z MOTHER'S=NAME (First, Middle,
<br />Thelma Chilton
<br />14a. INFORMANT -NAME
<br />Andrew Smith
<br />- 16a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />New Eminence Cemetery
<br />OME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />rat Home. 2929 S. Locust Street, Grand Island. Nebraska
<br />lab. LICENSE NO.
<br />1454
<br />CITY 1 TOWN
<br />Eminence
<br />CAUSE OF DEATH (See instructions and examples)
<br />I,:EnMstlle+dtre'dt►gems• -0isesasa, Merles, or cornplicatlens4Mt directly caused tha death. DO NOT Inert beano avant, such es cardiac arrest,
<br />ory atepjR,'ui variftfe aacritreNFiNon %emit showing the etiology. DO NOT AaEREVIATE. Enter oniyont cause an a SM. Add additional Niue N naceaary.
<br />IMMEDIATE CAUSE: )
<br />1f MALE;
<br />Notpngnantvdtidn-pap
<br />motor death ,
<br />-but pregnant widen 42 pegs d death
<br />raaantrih,43 days,to 1 gar before death
<br />guint ratted Ms pet year
<br />a) Unknown Natural Causes
<br />OR AS A CONSEQUENCE OF:
<br />Inoperable Aortic Aneurysm
<br />UENCE OF:
<br />NS Conditions contributing to the death but not resulting in the u
<br />idney Disease, Hypertension,
<br />A
<br />21a. MANNER OF DEATH
<br />Natural Q HonricIW
<br />Q Accident 0 Pending Investigation
<br />❑ Suicide Q Coutdnotb► determined
<br />cause given In PART 1.
<br />21tr: IF TRANSPORTATION INJURY
<br />❑ OrMnOpsrator
<br />❑ Passenger
<br />Pedestrian
<br />© Other (spay)
<br />19
<br />Yr.)
<br />000
<br />F INJURY (Mo., Day, Yr,)
<br />r
<br />� iNJUrtY Ai NfORK+l?;
<br />[YES...
<br />. TIME OF INJURY
<br />INJU
<br />, APT.NO.
<br />•Yr.)
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building,
<br />OCCURRED
<br />CITY/TOWN
<br />i J
<br />death occurred al the time, dab and place
<br />d. (Signature and Titbit
<br />TO THE DEA'41?
<br />UNKNOWN
<br />27.'NAME, WILE AND ADDRESS OF CER1TFIeR (Type or Print
<br />Farah Hinrichs, Hall Deputy County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />2AS.7 RE I S RAR'S SIGNATURE
<br />STATE
<br />04a;;oATE SIGNED (Mo., Deg, Yr.)
<br />: September 9, 2019
<br />t°RONOUNceu t.EAy) (Mn., T2ey,Yrr i 54
<br />September 7. 2019
<br />2 e. Oa the basis of examination andhx kw,adgaliaa, hi W- _
<br />tin time, dab and pia and due to the Cause(-) a*td, IMI l*
<br />Sarah Hinrichs, Hall Deputy County
<br />26a, HAS ORGAN OR NATION BEEN CONSIDERED?I 26b. WAS
<br />❑ YES bp NO
<br />26b. DATE FIt.EO BY i Q(STR AR. (Mo. Dat, YF
<br />September 1 3;12019
<br />
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