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<br /> 99 109383
<br /> MR�N THIS COPY CARItl�3 TF�RA/SED SEAL OF THE NEBRAS/GA F�i1lTH All�HUMAN 3�R1/ICES
<br /> S1rS1EA�IT CERiF�3 TF�BELOW TO BE A TRUE COPY OF TNE�NAL RECQ,B,Q�FIL,E W/TH
<br /> THE NEBRASKA HEALTH AND HUMAN SERV/CES SY3TEM,VITAL STAT/STIG,��D911��I IS lS�
<br /> THE LEDAL DEPOSITORY FOR VITAL RECORDS , _ -_- _- _ ��
<br /> DATE OF/S3UANCE �"� =,
<br /> APR 7 1998 �:U. ,aw.E,•s coct�,�:
<br /> as��ivr���4sr�'
<br /> UNCOLN,NEBRASIUI HEALTHAND�N.�A�DfZ`E�YS°l�ll�
<br /> � STA'fE OF NEBRASKA-DEPAR7MEN'f OF E�ALTH AND HUMAN S�$VICBS FQ¢ADICE ANB_SUPP(J&'1'
<br /> VITAI.STAT[S77CS - -_- -
<br /> CERTIFICATE OF DEATH -:Y =� __'
<br /> 1 DECEDENT�NAME FIRST MIDDLE IAST 2 SEX � �
<br /> - 3�t1ii__gFpEATH /Mprlh.DaY YBer/
<br /> Charles Fredrick Lange Male March 21, 1998
<br /> 4.CITV ANO STATE OF BIRTH lIlnd'n USA..�rns cpmyy/ Sa.AGE-Wst BirtMay UNDER 1 YEAR UNDER i DAV 6.DATE OF BIRTH /Mpry,,Day Yegr/
<br /> Wood River, Nebraska ��'g� 54 Sb M0S I DAVS s�HouRS MiNs
<br /> 7.SOCIALSECURTIVNUMBER Ma 2� 1943
<br /> 8a.PLACE OF DEATH
<br /> � 505-52-3635 HOSPITAL � inpatient OTHER � NursngMOme
<br /> 8b.FACILITV-Name /Hnd insOfufim,grve slreef and number/ -�...-- � ER OulpatieM � Res�Oence
<br /> � Lakeview Nursin Center O ��A � on,e�,so�,ty,
<br /> BC.,CITY.TOWN OR LOCATbN OF DEATH 8tl.tNSIDE CITY LIMITS 8e.COUNTY OF DEATH
<br /> Grand Island �BS (� No ❑ Hall
<br /> 9a.FESIDENCF-STATE 9b.COUNTY 9C.CITY.TOWN OR LOCATION 9d.SiREET AND NUMBER (lnduOingZip Cpde� 9e INSIDE CITV LIMITS
<br /> Nebraska Hall Grand Island 2515 W. John 68803 Yes� No❑
<br /> 10.RACE-(e.g.,White.Black.American pyian. 11.ANCESTRY�e.g..Ilalian.Mexican.German,etcl � 12�MARRIED ❑WIDOWED 13.NAME OF SPOUSE !I/wde.give maMen name/
<br /> etc.l Isceciryl ISOecMI
<br /> Ame r ic an DIVORCED
<br /> ite �AVER Colleen Wille
<br /> 14a.USUAL OCCUPATION /Grve kindd wqk dpne yminy mosl � 14b.NIND OF BUSINESS INDUSTRY � 15.EDUCATIpN ���
<br /> d workmg lile.Bven iliHrredl /'� ISVeciN only Mghgs�yraCe COm
<br /> Salesman ° �) ElementarywSecandaryioi2� Couega��.aor5•i
<br /> Car Dealershi 1 Year
<br /> 16.FATHEH-NAME FIRST MIDDLE LAST 77 MOTHER FIRST MIDULE MAIOEN SURNAME
<br /> William NMN Lan e Frieda Ann Baeder
<br /> 18.WnS DECEASED EVER iN U.S.ARMED FpRCES? tga.INFORMANT-NAME -
<br /> (Vee.no.+•unk.� ,'�I yes.give war antl tlates M servkes�
<br /> No National Guard 1963-1969 Colleen Lan e
<br /> 79b W��RMANT MAILING ADDRESS ISTREET OR H.F.D.NO..dTY OFl TOWN.STATE.ZIP� -
<br /> 2515 W. John, Grand Island, Ne. 68803
<br /> 20. 6nl6�EP�giGNn7URE 8 UCENSE N0. 21a.ME71i0D OF pSPOSt7�ON 2ID.DATE 2�c CEMETERV OR CREMniORV-NAME
<br /> R• ��� ���43 �e���a� ❑Rz,no�a� Mar. 2�F, 1998 Westlawn Memorial Park
<br /> i22a.FUNERAL FIOME�NAME 21tl.c;EMETERV O�CFEMATOAV LOCATION GTV OR TOWN STA7E
<br /> Livingston-Sondermann F.H. ❑Cremalqn ❑o��a��o� Grand Island, Nebraska
<br /> 22b.FUNERAI HOME ADORESS �STREFT OR R.F.D.NO..pTV OR TOWN.STATE.21P� �-�-
<br /> 601 N. Webb Road, Grand Island, Ne. 68803-4050
<br /> 23. IMMEDIAT CAUSE (EN7ER ONIY ONE CAUSE PER IINE FOR ia1.Ib1.AND�cp i Intervai Oetween anse�and aeam
<br /> PART -
<br /> �a�
<br /> , ' � �
<br /> DUE TO,OR S A C EOUENCE OF. �
<br /> i hNerval onset antl Oeain
<br /> Ibl �
<br /> I
<br /> DUE TO.OR AS A CONSEOUENCE OF� -�"-�� - - -r . _ �
<br /> � Imeroal be�ween onser anA oeain
<br /> Iq i
<br /> OTHER SIGNIFICANT CONDITIpNS-CpWitions conhibuting to tl�e tleath Eul rqt related PART III IF FEMALE.WAS iHERE A 2a AUTOPSY 25 WAS CASE HEFERREO TO MEDICAL
<br /> PART
<br /> II PREGNANCY IN THE PAST 3 MONTHS? `' _ �EXAMINER OR CORONER'+
<br /> �f " `/
<br /> IAqes 10-51� Ves No Ves No �� Ves No
<br /> �a 26b.DATE pF INJUFV /Mp,pay.yc/ 26c HOUR OF INJURY 26A.DESCRIBE HOW'NJURV pCCURRED
<br /> � Acc�tlEn1 � Untlelerm�np�
<br /> M
<br /> � Su�uGe � pend�ng 26e IN�URY AT WORK Z61.PIACE QF INJURV�qt f�orr�e.tarm.streei.laclay 26g LOCATION STREET OR P.F.D.NO. CI7Y OFl TOWN
<br /> ❑ ❑ ❑ oflice bmldirg,etc /Spec�y/ SrnrE
<br /> Nomi�itle invesuganon Ves NO
<br /> 27a DATE OF DEATH /MO Oay Yr./ 28a DATE SIGNED /MC Day Yr1 28b TIME OF DEATH
<br /> �a X March 21, 1998
<br /> � 27b DATE SIGNED /MO.Day Yr.) 27t TIME OF DEATH �N cF¢i M
<br /> 28c PRpNOUNCED DEAD /Mo_Day,YrJ 28G.PRONOUNCED DEAD /h'aur
<br /> g�o .'d�larch 24 998 �3:25 AM �N�o
<br /> M g z M
<br /> n 27A 7o Me Oest ol my letl .tlea occurreC at tbe tl , ate antl place anA Eue to tne °�� 29e.On the basis ol ezammaGOn antl�or invasu atron,in m
<br /> ��eauselsl stated. ° � the ume.aale an0 place anA tlue lo Ihe cause1515tate0.���aeaM occurreA a�
<br /> .�
<br /> IS natme and Title) � �S�naWre antl iitle��
<br /> 29.DIO TOBACCO USE CON T O THE DEATH? 3p.a HAS OHGAN OR TISSUE OONATION BEE CONSIDERED? 30.0 WAS CONSENT GRANTED7
<br /> � � VES O � UNKNOWN � VES NO � YES NO
<br /> 3t NAME AND ADDRESS O CERTIFIER�PHySIC1AN,CORONEfiS PHVSICIAN OR COUNTV AT70RNEVI l7ype a inry
<br /> X Dr. John A. agoner, M 800 N. Alpha, Grand Island, Ne. 68803
<br /> 32a.REGISTRAF
<br /> 32C.DATEFILEDBV��AR�/���998
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