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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN S SYSTEM, R MMES THE BELOW TO SEA TRUE COPY OF THE OR1G1NAL RECORLL M THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS4�' THE LEGAL DEPOSITORY FOR VITAL RECORDS. s __ r -- DATE OF ISSUANCE s _ NOV 14 2003 20040 3910 A LINCOLN, NEBRASKA HEALTH AI i> _ SrA,EOFIEIASL DW,►KMENTOFMUIH,►MMMA 1$51V1=, 4692 VIfALSTA'nSTIL•S C'MTMCATE OF DEATH _ DEC -NAME FMT MIDDLE LAST 2 SEX 3 DATE OF DEATH 44— rA r viw Otto C. Hauschi Male J . 26 2001 4 CITY AND STATE OF BIRTH i01of nV SA /MIfe COYMrr 59 AGE - LM &'I Ift UNDER t YEAR 7IIIpER DAY 6 DATE OF 81PT« .Abnlr Oft YOW Ravenna, Nebraska �� 81 S° "0S DAYS x nolRa ArNS March 22, 1919 - -_ - i SOCIAL SECURM NUMBER as PLACE OF DEATH IgSMTAL El walk" OTHER ❑ TAtsllq H / e 0 FACILITY - AWM I#roW dff*m Q'Ye Slant and JMn111V1 ❑ ER QIIPWWW ❑ ft*O ! ❑ DOA ❑ St s L+�ediC81 , °"e` '°"'' - -- - ! CITY TOWN LOCATION OF DEATH - _ - •. -- - i Yes ®Nc Hall 9• RESIDENCE -STATE , 90 COUNTY 9< CTV TOWNOR LOCATION 390 STREET AND NUAMEN r...Pn,7o c..at: + ft s" Ca .Wv Grand Island 2326 N. Lafayette 68803 Y• No ❑ Aka Ha 7q RACE - M-¢ Who. NO. Amwcm llayn 11. ANCESTRY M q 84A8n. Msl�can. fiernlAn. tx: t2 ®MARRIED C'i WIDOWED � t3 NAME OF SPOUSE d r-t o.rRlFan'c '.r'^r ± fsoeclNl NEVER L ❑1 —ED L. Kriha, 4ler!SolIC4F, White f MARRIED 148 USUALOCCUPATION /rrleulaaAm abn/aYla19aloer 1Ab I7e1D OF BUSINESS INDUSTRY 15 EOUCATM :SW#, 0-W nglMAt iTaOl 10^MMMGI &� � puent Operator Maintenance �1 rw , C~ _ T8 FATHER - NNE FIRST MIDDLE LAST 1 • T MOTHER - FIRST MDOL£ YAIDEN SIRUNAAE _ Albert P. Haus —bild i Marie A. Ahrens _ 7B YYAS DECEASED EVER IN U S ARMED FORCES' 194 e60RMANT - NAME IYA4. oo a l+sl l I (Y VOL gwo w ow deMS d mw.*Q WIR i Rose L. Hauschild -- LSL i L aaL . -- - D EMBALMER- BK,NAT LICENSE NO I2ta METIgpOF 01$POSiTM,,N j2tD DATE '27c CEMETERY OR CREMATfjI++ NNK Service Not HmbaLned ❑ MI ❑ Remoras Jan. 26, 2001 Central Nebraska Cremation FUNERAL Ip4E -.NNE 21d CEMETERYORCPEMATOPVLOCATION -17 �JWN STATF ®�"n"'oA ❑ Dome Gibbon, Nebraska 0 FUNERAL NOTE ADDRESS ISTREET 0.f 0 NO CITY OR TOWN. STATE. ZIP) 719 Front St. , PO Box 10 Gibbon Nebraska 68840 NMAEOIATE CAUSE (ENTER ONLY ONE CAUSE PER LIE FOR 3.!01 AND ftil O1M'•r °ss""' P"'A 0-•'c "" PART C �� Vet P %0 • ��. p DUE TO OR AS A CONSEQUENCES OF /� /' - YIr r �� Ilre1 0-•r• kr Z) /0 C, — DUE TO OR AS A CONSEQUENCE OF - rr..a salwen en1,el r.: �r-.Y A. R convia0%0 vw d"m but TO 'wow PART MIF FIRM►E WAS A OPSv - WAS USE REFERRED 70 MEDICAL PART PREGNWIMACY IN THE PAST 3 MONTHS, AMW*R OR COR014R II - .. "0 10-541 . Y$6 No Y$6 r0- No Yes NO 250- 2511 DATE OF RAARW IMb DW Wf 26C HOUR OF PWRY 28C DESCREIE HOW IIIARW OCCUIMIED 1 ❑ AlxgwB ❑ 7A10PemYnea I y C] 51nFM [] PerMwg 2TM el.A1RY A7 WORM 281 PLACEM MA % ILO frm slreM I&Mv 2E9 LOCATION STREET OP R F D NO CITY OR TOWN STATE dk. dW,., ❑ Hoo K M18Mgsson I Yes ❑ No ❑ I IOATIE OF DEATHH� 1W Olp, Yrf 2" DATE SIGNED 4A. Dar v • 2811 TIME OF DEATv OLfi 0DDA7 300" Ab ow r, t 2rc TIME OF MATH �p, F ° y 28c PRONOUNCED DEAD .4b Ow. V � ! 28o PRONOUNCED DEAD iFbv E Mj E 8 Vd To go bW of I" a aeA91 xyrt' 0-M also 4H' = 2r On IM OfO d as Kea Ana m n. m4 eo'I imaw oPron Dear occlne0 x 1 eauws: tIM40. � � aM Une Oft aro dace Ana eiM b uM caur[fs; t11Na T ,c..,,,., .. e,gT Ana TMr � —DID Ty F ow=US_ CONTRMi TO THE DEATH' We HAS ORGAN OR TIE DONATION SEEN DERED'� �sy 'YID WAS CONSENT GRANTED' YES N SSU ❑ UWNOWN 1 ❑ YES �T11TT I ❑ YES �- 31 NAME AND ADDRESS OF CERTIFER- PHYSKLAN. CORONERS PHYSICIAN OR MINTY ATTORNEY. Tlfltl Prw! Kenneth L_ M*tel tom,x 21J6 W Faidley #400• Grand Islarnda Nebraska 68803 ]an DATE FILED SY PEGtsT%AP alb M If, a ■/ F FnQ VITAI CTATICTII R I1CF nN1 V -_ A