|
WHEN THIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEK IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD. ON FILE ]KITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTM �£T� 3 I
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />A
<br />DATE OF ISSUANCE _ x
<br />�►b
<br />SEP 2 5 2001 & ASSISTA #r - —
<br />LINCOLN, NEBRASKA HEALTH AND HliWllF; -
<br />4;
<br />20011 X588 = -
<br />STATE OF NEBRASKA — DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH tj _ i'l q 79 07797
<br />DECEDENT -NAME FIRST MIDDLE LAST
<br />EK
<br />GATE Of DEATH (Mo.. Day, Yr.)
<br />1
<br />John Herman Hiedfelt
<br />Male
<br />23, 1
<br />,.
<br />3.July
<br />RACE -Wo., WbiN. Bloc .American
<br />ONGINIDESCENT(..g., belies. Mexican. AGE
<br />-Lee siabd.y
<br />UNDER 1 YEAR
<br />UNDER 1 DAY DATE OF BIRTH (Me.. Day, Yr.)
<br />MOS. . DAYS
<br />Iwdi.w, ek,)OP -4)
<br />Gervnen, wk.) (Specify) ; 0 tyre.)
<br />HOURS . MINS.
<br />_ A. kite
<br />60.
<br />6b.
<br />6c. 7.
<br />CITY AND STATE OF BIRTH ( aeF is U.S.A., CITIZEN OF WHAT COUNTRY
<br />MARRIED,
<br />NAME OF SPOUSE (►t
<br />none Cavalry)
<br />Island.
<br />IMARRIED.NEVER
<br />WIDOWED. DIVORCED (specify)
<br />iedfelt
<br />B. Grand
<br />SOCIAL SECURITY NUMBER
<br />UAL OCCUPATION (Gi.. find el.ork dene daring wvoct KING OF BUSINESS OR INDUSTRY
<br />COUNTY DEA H
<br />— kintAfe, — iF retire f )
<br />Ea. Owner an 113b.
<br />114s.
<br />i2.505-44-3536A
<br />rator �t,<s Construction
<br />RAU
<br />CITY, TOWN OR LOCATION OF DEATH INSIDE
<br />CITY LIMI S
<br />HOSPITAL OR OTHER INSTITUTION- Nome (IF not iw either,
<br />IF NOS►. W INST. Iwd;ceve DOA
<br />(Specify.
<br />Grand Island
<br />Y« or No)
<br />gve dreN and w.mber
<br />kemorial '
<br />atiewew. l-er. am. mpe*o w (Sp.4)
<br />,db. ,k.
<br />es
<br />,.dZ,utheran Hos tat
<br />lw. Emer. Rm
<br />RESIDENCE -STATE
<br />COUNTY
<br />CITY, TOWN OR LOCATION
<br />STREET AND NUMBER INSIDE CITY LIMITS
<br />ISa_ Nebraska
<br />,Sb. Hall
<br />,sc. Grand Island
<br />(Specify Yee or me)
<br />lim. 1120 E. Bismark Rd, Y
<br />PATHIR-HAMI FIRST MIDDLE LAST
<br />MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />William Niedfelt
<br />E E R IN UA ARMED FORCES?
<br />(Yev e MH OR
<br />11 M
<br />fOU
<br />INFORMANT -NAME (STREET OR R.F xSTATICMOl
<br />of
<br />,B. NO
<br />lv. Mrse Florence Niedfelt- ife- 120 E. Bismark Rd., r
<br />BUMAL,Cr.vnotion, Removal
<br />CEMETERY OR CREMATORY -NAME LOCATION
<br />CITY OR TOWN STATE
<br />me. Burial
<br />C-7/25/79
<br />2a. Grand Island Ci Md.
<br />Grand Island NE
<br />EMBALMER - SIGNATURE B LICENSE NO. IL889
<br />FUNERAL HOME -NAME AND ADDRESS (STREET W R.F.D. NO.. CITY OR TOWN, STATE, Zlry WWI
<br />Sondermann's,505 W.Koenig, Grand Islandg Ne/
<br />2/
<br />22.Livingston-
<br />To the of my -e. yr ewe Piece *ad r.. ve. Me
<br />j \`/ ♦_\
<br />=.�i Ow
<br />i S Me
<br />M.. bw .1 e.e -;w.. ewww ;w eciew. in
<br />n-e. clove ed Piece ewd be ve M. co.rl4 wved.
<br />23e.fSi,wer.reewlrvlb) % f1 t\ iMf7
<br />i;0 t1e(f;.e.rw..wdT;de)�
<br />A��.=.<>
<br />DA SO NED (Mo.. Day, Yr.)
<br />HOUR OF DEATH
<br />Me. Day, Yr.)
<br />HOUR OF DEATA
<br />?]b. � �
<br />123c. 10:3b A M
<br />i•
<br />�: 2 z
<br />LAC. M
<br />i
<br />tab.
<br />DATE OF DEATH (Ms., Day, Yr.)
<br />DEAD
<br />PRONOUNCED DEAD (Hour)
<br />PRONOUNCED
<br />~
<br />-� -`
<br />(Me.,
<br />"
<br />Day, Yr.)
<br />tad.
<br />24e. M
<br />NAME AND ADDRESS E MINK IAN, C ER'S PHYSICIAN OR COUNTY ATTORNEY) (Type of Pr;wl)
<br />John J. Cannella, Me D. 729 North Custer Ave., Grand Island, Ne. 68801
<br />2.
<br />REGISTRAR DATER
<br />) ED BY REGISTRAR (MO., Do,, Yr.)9
<br />26a (Sl,eer.n):~ 16
<br />IMMEDIATE CAUSE i NFER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (c)) lwveel bev.eew exist sad deevb
<br />/ART ti vv
<br />`` ��StZat
<br />Oba ' `` v� Mo
<br />DUE TO. R AS A CONSEQUENCE OFI , Iw be#.*" woo sad death
<br />DUE TO. OR AS A CONSEQUENCE Oft Iwver,el bew.e.a earn ewd deedv
<br />x , ,
<br />FART^ u1mcm 300oHIFICANT ON01 �-Cewditieec cowaibwi.9 ve eoM b.v ral.ved ►ARr
<br />;r r tom, + . ,. s ',: , . PREGNANCY
<br />Q 'v,'V x., r ~
<br />111. Ir fEMwIE. WAS THERE A
<br />IN THE PAST Z MONTNST
<br />AU1gSY ,///���.����
<br />( Speciy Y« e
<br />WAS CASE REFERRED TO MEDICAL
<br />EIIAAUNIS OR jrDBOHER
<br />Specify Y« e.M`e)Jl
<br />i Z ` C
<br />Yes O No O
<br />V
<br />29.
<br />29.
<br />xy ACCIDENT 101 MOMICIDl, U04091
<br />±¢ SIIGATION.tfpecify)
<br />PAT! Of INJURY (Me., DoY, Yr.)
<br />�J3
<br />HOUR OF IWURY DlSCMRl.
<br />Od
<br />NOW INIURY OCCUMtD
<br />.�.. - /(
<br />we
<br />Sob.
<br />w�. 3 M aod.
<br />o C L
<br />�
<br />- MUURY AT WORM :
<br />(S NY r..
<br />'
<br />PLACR OF INIURY- Atbee.e, is,., preev, Lowery.
<br />ellke beildiae, specify)
<br />WCAT STREET OR II.r.0. tie. CITY OR TOWN STATE
<br />y,
<br />�V
<br />30e. , v 0
<br />30F. OZ
<br />n ,
<br />0
<br />
|