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DOUGLAS COUNTY HEALTH DEPARTMENT
<br />Vital Statistics Section
<br />200401690 ;Z 13133
<br />OMAHA, NEBRASKA
<br />CERTIFICATE OF DEATH
<br />12.82
<br />This certifies this document to be a true copy of an original record on file
<br />with the Vital Statistics Section of the Douglas County Health Department,
<br />Omaha, Nebraska. Certified copies must have a raised seal in the area to the
<br />left. Reproductions) of this green certificate are not legal copies.
<br />'11,h -7,4
<br />Date issued: .JAN 1 3 1989
<br />t (Registrar)
<br />DECEDENT -NAME FIRST MIUUEt ,�eJl i� ^•` "' °""" •'-'- • - -r•- '
<br />I
<br />Theresa Lorraine_ B'ornber 2Female 3_Janu_ar 8_,_j989_— _______
<br />RACE - (e.g.. White, Black, American CKtIGIN /DESCENT (e.g., II.I_, Me.icon, i AGE -Lot+ O.nhd.y UNDER 1 YfA_R_ UNDER_ 1 D_AY DATE OF BIRTH (Mo . Doy, Yr )
<br />{.
<br />Indian, .k.) (Specify) German, etc ) (Specify) (Yr..) MOS - DAYS HOURS MINS
<br />68 '6 1? February 1, 1920
<br />4 White S. American_ _1b .
<br />CITY AND STATE OF BIRTH (If riot In U.S.A., CITIZEN OF WHAT COUNTRY MARRIED. NEVER MARRIED, I NAME Of SPOUSE (If w+fe. 9�w m-d., name)
<br />iWIDOWED. DIVORCED(Spe<dy)
<br />name country)
<br />Omaha Nebraska v. U. S. A. ;to Married Carl A. Bjornberg
<br />_I„
<br />SOCIAL SECURITY NUMBER USUAL OCCUPATION (Gi.. kind of work done dur+n9 moct KIND OF BUSINESS OR INDUSTRYiCOUNTY Of DEATH
<br />I
<br />of +corking )if., even if retired)
<br />12 506 -16 -7370 113a Housewife 13b At Home 14a Dou Las
<br />- l- -- - $ - - -' --
<br />_ _ SP
<br />CITY, TOWN OR LOCATION OF DEATH INSIDE CITY LIMITS HOSPITAL OR OTHER INSTITUTION - Nome (If not in edh.r, • IF NOSP OR tNSi Indco.. DOA.
<br />HOSPITAL
<br />Ou+po+.e!rEme, Rm . fnpo+..ri+ (So.<dyl
<br />f Specify Ye. or No) give or and numbed
<br />Omaha ,4c. es 14d Clarkson Hospital _- _�l.eInpatient
<br />,46. — __—
<br />RESIDENCE -STATE COUNTY CITY, TOWN OR LOCATION i STREET AND NUMBER INSIDE CITY LIMITS
<br />(Specify Ye, or No)
<br />306_ East 20th Street
<br />,Sa. Nebraska 1sb. Hall 1st. Grand Island ,Sd 115. yes
<br />-NAME FIRST MIDDLE LAS: MOTHER - MAIDEN NAME FIRST MIDDLE LA T
<br />Carl E. Swanson I17 Lydia Johnson
<br />VFATHER
<br />AS DECEASED EVER IN U.S. ARMED FORCES? INFORMANT- NAME - RELATIONSHIP � -- MAILING ADDRESS (STREET OR R F D NO. CIT. OR TOWN. STATE, ZIP)
<br />do,., 30 A 29th Stre��801
<br />ne, ar .nk)I (I, yet. III- _er °rid of ..r.,<., .East
<br />no 19 Carl A. Bjornberg husband, Cyrandsan.d, NF
<br />AL, Cremation, Removol DATE CEMETERY OR CREMATORY - NAME i LOCATION CITY OR TOWN STATE
<br />20a. Burial 20b. 1/11/89 20c. Forest Lawn Cemetery I20d. Omaha, Nebraska _
<br />EMBALMER - SIGNATURE A LICENSE NO. FUNERAL HOME -NAME AND ADDRESS (STREET OR R f D NO, CITY OR TOWN, STATE, ZIPI
<br />2/s/ R.J. Wessling 2355 22, Roeder _M_o_rtuar 2727 North 108th St.Oma.ha,Ne.68134
<br />F DEATH (Me., Day, Yr.) DATE SIGNED (Mo Doy, Yr.) HOUR OF DEATH
<br />i>
<br />t.z B<i
<br />1 -8 -89 24o. 246. M
<br />vv _ pup
<br />='n IGNED (MO., Doy, Yr.) HOUR OF DEATH a: <.> PRONOUNCED DEAD PRONOUNCEDDEAO(Hour)
<br />.>
<br />azg f (Mo .,Doy,Yr.)
<br />[3b
<br />E 1 -10 -89 11:00 A
<br />v 23c. M W j 24c. . 24d. M
<br />.1 my ►no�ledye. death ec<urr.d o+ Me rime, do+. oed plot. and d.. to the 1 e p0 On +he bawl of .. m�notwri orid /er n..++i9 +ieri, .r. my op,e ion d.o+I. «curr.d
<br />te0U the bm., del. and plan °ed d.. toy III. co w( +) Icl.d
<br />'ttd �
<br />s Randal S. Casslin MD O ° 24e.(S,9no+.r. and Lll.i.
<br />� / % g I
<br />gnawr. end rfl.l ►
<br />NAME AND ADDRESS OF CERTIf IFR (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or P-1)
<br />Randal S. Cassling, M.D. 465 Drs' Bldg Omaha,NE
<br />25
<br />REGISTRAR ) ;� !�? J I (DATE RECEIVED 8Y REGISTRAR (MO . Doy. Yr.)
<br />�
<br />JAN 3 1888
<br />1St- s./.5..�rG.��, � 'y!• J��j 1
<br />�ei'►>t� 1266.
<br />-i'4 ' lLy
<br />26a. f Sig nofurel ' • —
<br />27. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINFV.rfOR (o), W. AND (c)) Iri+r al be'-.- on.a rd death
<br />PART '
<br />°) Renal failure
<br />DUE TO, OR AS A CONSEQUENCE OF: Ina vol b.-+ —.l d d.cth
<br />Congestive heart failure
<br />,b)
<br />� Intrrvol bet....n onset and deaM
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(c)
<br />PART OTHER SIGNIFICANT CONDITIONS - C °nd:tiom <ontributinp to death bur not .dared I PART III IF FEMALE, WAS THERE A i AUTOPSY I WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY IN THE PAST 3 MONTHS? (Speuly Yn or No) 1 EXAMINER OR CORONER
<br />-
<br />I
<br />11 (Sped, Y.t er No)
<br />j Yes ❑ No 128 n0 49 n0
<br />ACCIDENT, SUICIDE. HOMICIDE, UNDEi., DATE OF INJURY (Me., Day, Yr.)
<br />HOUR Of INJURY
<br />DESC RIRE MOW INJURY OCCURRED
<br />OR PENDING INVESTIGATION. (Specify) I
<br />300. 30b.
<br />30c. - M
<br />30d.
<br />INJURY AT WDtK
<br />PLACE OF INJURY- At home, form. Ofeet, factory,
<br />LOCATION STREET OR R F D No. CITY OR TOWN STATE
<br />/specify Y.. er Ne)
<br />elfin buildln9, etc. (Specify)
<br />30..
<br />30f.
<br />30g.
<br />12.82
<br />This certifies this document to be a true copy of an original record on file
<br />with the Vital Statistics Section of the Douglas County Health Department,
<br />Omaha, Nebraska. Certified copies must have a raised seal in the area to the
<br />left. Reproductions) of this green certificate are not legal copies.
<br />'11,h -7,4
<br />Date issued: .JAN 1 3 1989
<br />t (Registrar)
<br />
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