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<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />Ervin August Bernstrauch
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<br />May 8, 2003
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<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
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<br />CA
<br />5c. HOURS M1NS.
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<br />September 1, 1923
<br />Monowi, Nebraska
<br />7
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<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />p
<br />507- 20-3282
<br />HOSPITAL, ITAL ❑ Inpatient OTHER_: ❑ Nursing Home
<br />❑ ER Outpatient Residence
<br />N
<br />'
<br />❑ DOA ❑ Other (Specify)
<br />Sc. CITY, TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
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<br />9a. RESIDENCE -STATE -
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<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER tlnc /udingrZip Code)
<br />9e. INSIDE CITY LIMITS
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<br />Z�-
<br />230 South Kimball St. 68801
<br />Yes [91 No ❑-
<br />CD
<br />11. ANCESTRY le.g.. Italian. Mexican, German, etc)
<br />12. MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (It wile. give maiden name/
<br />etc.) (Specify) White
<br />(Specify) American
<br />NEVER DIVORCED
<br />1 Marie Smith
<br />RI
<br />14a. USUAL OCCUPATION /Give kind of work done dunng most 14b.
<br />=3
<br />15. EDUCATION
<br />(Specify only highest grade completedl
<br />Element ory or Secondary 10 -121 1 College 11 -4 or 5 -1
<br />O
<br />of working kfe, even Aree'red) Parts Mechanic
<br />Implement Company
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />DO
<br />�17.MOTHER
<br />Paul Bernstrauch
<br />Clara Fahrenholz
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />�'ea. no. or unk) III yes. give war and dates of services) W W II
<br />on
<br />C7
<br />yes November
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />230 South Kimball St., Grand Island, Nebraska 68801
<br />20.E ER- SIGNATU LICENSE NO
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<br />WHEN THIS COPY CARRES TIE RAISED SEAL OF THE NEBRASKA H Al A 1 MR SERVICES
<br />SYSTEIIC IT CERT FES THE BELOW TO BE A TRUE COPY OF T1E 011 01NAL 14N €IC WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, WTAL'STAT1$T ES CTIdN,- Y1�f�K .S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE = _d
<br />5/14/2003 200401373
<br />���Oi
<br />ASSISTANT STATE REG1$1 _
<br />LINCOLN, NEBRASKA HEALTH A
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVIES FII� ANIkiPPORT
<br />VITAL STATISTICS _ -- 0 3 05358
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />Ervin August Bernstrauch
<br />Male
<br />May 8, 2003
<br />4. CITY AND STATE OF BIRTH tit not in U.S.A. name country/
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER t DAY
<br />6. DATE OF 81RTH /Hoof. Day. Year/
<br />MOS. I DAYS
<br />5c. HOURS M1NS.
<br />(Yrs.) 79 Sb.
<br />September 1, 1923
<br />Monowi, Nebraska
<br />7
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />p
<br />507- 20-3282
<br />HOSPITAL, ITAL ❑ Inpatient OTHER_: ❑ Nursing Home
<br />❑ ER Outpatient Residence
<br />8b. FACILITY -Name (Nnotinsftilort give street and number)
<br />230 South Kimball St.
<br />❑ DOA ❑ Other (Specify)
<br />Sc. CITY, TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
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<br />9a. RESIDENCE -STATE -
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER tlnc /udingrZip Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />230 South Kimball St. 68801
<br />Yes [91 No ❑-
<br />CD
<br />11. ANCESTRY le.g.. Italian. Mexican, German, etc)
<br />12. MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (It wile. give maiden name/
<br />etc.) (Specify) White
<br />(Specify) American
<br />NEVER DIVORCED
<br />1 Marie Smith
<br />RI
<br />14a. USUAL OCCUPATION /Give kind of work done dunng most 14b.
<br />=3
<br />15. EDUCATION
<br />(Specify only highest grade completedl
<br />Element ory or Secondary 10 -121 1 College 11 -4 or 5 -1
<br />O
<br />of working kfe, even Aree'red) Parts Mechanic
<br />Implement Company
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />p
<br />�17.MOTHER
<br />Paul Bernstrauch
<br />Clara Fahrenholz
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />�'ea. no. or unk) III yes. give war and dates of services) W W II
<br />v�
<br />yes November
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />230 South Kimball St., Grand Island, Nebraska 68801
<br />20.E ER- SIGNATU LICENSE NO
<br />21 a. METHOD OF DISPOSITION
<br />c1
<br />N
<br />#1071
<br />❑ Bunal 1:1 Removal
<br />May 13, 2003
<br />Westlawn Crematory
<br />NERAL HOME - NAK49
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
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<br />CD
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />2929 S. Locust St., Grand Island, Nebraska 68801
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<br />DUE TO, OR AS A CONSEQUENCE OF Interval ldeen onset and death
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<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />I
<br />I
<br />(c)
<br />CIS
<br />III IF FEMALE. WAS THERE A 24
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<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />0
<br />w
<br />WHEN THIS COPY CARRES TIE RAISED SEAL OF THE NEBRASKA H Al A 1 MR SERVICES
<br />SYSTEIIC IT CERT FES THE BELOW TO BE A TRUE COPY OF T1E 011 01NAL 14N €IC WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, WTAL'STAT1$T ES CTIdN,- Y1�f�K .S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE = _d
<br />5/14/2003 200401373
<br />���Oi
<br />ASSISTANT STATE REG1$1 _
<br />LINCOLN, NEBRASKA HEALTH A
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVIES FII� ANIkiPPORT
<br />VITAL STATISTICS _ -- 0 3 05358
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />Ervin August Bernstrauch
<br />Male
<br />May 8, 2003
<br />4. CITY AND STATE OF BIRTH tit not in U.S.A. name country/
<br />5a. AGE -Last Birthday
<br />UNDER 1 YEAR
<br />UNDER t DAY
<br />6. DATE OF 81RTH /Hoof. Day. Year/
<br />MOS. I DAYS
<br />5c. HOURS M1NS.
<br />(Yrs.) 79 Sb.
<br />September 1, 1923
<br />Monowi, Nebraska
<br />7
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />p
<br />507- 20-3282
<br />HOSPITAL, ITAL ❑ Inpatient OTHER_: ❑ Nursing Home
<br />❑ ER Outpatient Residence
<br />8b. FACILITY -Name (Nnotinsftilort give street and number)
<br />230 South Kimball St.
<br />❑ DOA ❑ Other (Specify)
<br />Sc. CITY, TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />Yes ® No ❑
<br />Hall
<br />9a. RESIDENCE -STATE -
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER tlnc /udingrZip Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />230 South Kimball St. 68801
<br />Yes [91 No ❑-
<br />10. RACE -(e.g., White. Black. American Indian.
<br />11. ANCESTRY le.g.. Italian. Mexican, German, etc)
<br />12. MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (It wile. give maiden name/
<br />etc.) (Specify) White
<br />(Specify) American
<br />NEVER DIVORCED
<br />1 Marie Smith
<br />RI
<br />14a. USUAL OCCUPATION /Give kind of work done dunng most 14b.
<br />KIND OF BUSINESS INDUSTRY _
<br />15. EDUCATION
<br />(Specify only highest grade completedl
<br />Element ory or Secondary 10 -121 1 College 11 -4 or 5 -1
<br />O
<br />of working kfe, even Aree'red) Parts Mechanic
<br />Implement Company
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />FIRST MIDDLE MAIDEN SURNAME
<br />�17.MOTHER
<br />Paul Bernstrauch
<br />Clara Fahrenholz
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />�'ea. no. or unk) III yes. give war and dates of services) W W II
<br />Marie Bernstrauch
<br />yes November
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />230 South Kimball St., Grand Island, Nebraska 68801
<br />20.E ER- SIGNATU LICENSE NO
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />#1071
<br />❑ Bunal 1:1 Removal
<br />May 13, 2003
<br />Westlawn Crematory
<br />NERAL HOME - NAK49
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />All Faiths Funeral Home
<br />®Cremation ❑ Donation
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />2929 S. Locust St., Grand Island, Nebraska 68801
<br />23. IMMEDI AUSE c ONLY ONE CA U E PEA LINE FOR fal. (b). cll I Interval between onset and death
<br />,�(ENTER
<br />�
<br />-_- j�
<br />PART %F�
<br />I
<br />v/ , •v 7+vY'G �LJ�
<br />lal I
<br />DUE TO, OR AS A CONSEQUENCE OF Interval ldeen onset and death
<br />I
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />I
<br />I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the dsWt but not related PART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />11
<br />- - (Ages
<br />10 -541 Yes No
<br />Yes No X
<br />Yes Na X
<br />26a.
<br />26b. DATE OF INJURY /Mb.. Defy. Yr.)
<br />25c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Undetermined
<br />Accident
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />2&. P -, INJ� ;N 1_ 'o1Pe, farm. seeet. factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes E] No E]
<br />Jpe�YI
<br />27a. DATE OF DEATH (Alo.. Day. Ycl
<br />28a. DATE SIGNED (Mo.. Day. Yr.)
<br />28b TIME OF DEATH
<br />May 8, 2003
<br />M
<br />� �
<br />27D. DATE SIGNED (Afo.. Day. Yr.)
<br />27c. � TIME OF DEATH �
<br />28c. PRONOUNCED DEAD /Mo.. Day, Yi/
<br />28tl. PRONOUNCED DEAD (Hour)
<br />4
<br />May 1"2,
<br />8:30 A M
<br />�
<br />w =
<br />M
<br />27d. To the bast dl my ocyrrrred aatt'the 6rOB, dste plebe vej d e b the
<br />'28e. -On the basis d examination arid, or investigation, in my opinion death occurred at
<br />° c°�
<br />causeI. staled.
<br />//!/
<br />c> b
<br />the time. date and Place and due to the cause(s) stated.
<br />(/l. !
<br />(S' nat re and ► -
<br />(Signature and Title ) No
<br />29. DID TOBACCO USE E DEATH?
<br />HAB ORGAN OR TISSUE DONATION N CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />❑ YES NO ❑ UNKNOWN
<br />❑ YES NO
<br />❑ YES NO
<br />31. NAME AND AODRES F 16i (PHYSICIAN, CORONER'S PHYSICIAN OR COUNT( ATTORNEY) /Type or t1
<br />John A. Wagoner, .D., 800 AI ha ., Grand Island, Nebraska 68803
<br />32a- REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Ma. Day. Yr.)
<br />Olt
<br />MAY 13 2003
<br />
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