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<br />a
<br />w'
<br />WHEN THIS COPY CARII S THE RAISED SEAL OF THE NEBRASKA HEAL 7; iM11, 0i SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL LFCORD i©N FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL $TIP 0170N, WHICH is
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />0OT�
<br />4/13/2004 2004041,94 OPAR
<br />- gSS /3�1AFT�'A'1���GiSTRNR
<br />LINCOLN, NEBRASKA HEALTWAND � SYS YI
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN 399WC2 AN AND SUPPORT 03853
<br />CERTIFICATE OF DEATH _ 04
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH (Month. Day. Year)
<br />Karlene Emma Lambrecht
<br />Female
<br />March 29, 2004
<br />a. CITY AND STATE OF BIRTH til not in U.S.A.. name country/
<br />Sa. AGE -Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH tMonlh. Day. Year)
<br />rn
<br />:3
<br />Sc. HOURS' MINIS.
<br />Grand island, Nebraska
<br />(Ym.l 62
<br />August 20, 1941
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. 'PLACE OF DEATH
<br />M
<br />© ❑
<br />505-54-4289
<br />��
<br />o
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY - Name /N nol institution, give street and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other ( Specify,
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMITS
<br />rM
<br />(In
<br />Yes ❑x No ❑ i
<br />Hall
<br />z
<br />9b. COUNTY
<br />c�
<br />9d. STREET AND NUMBER ilnciuding Zip Code)
<br />9e. INSIDE CITY LIMITS
<br />Z
<br />Hall
<br />Wood River
<br />14590 S. Prosser Road 68883
<br />Yes ❑ No
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian, Mexican, German, etc)
<br />M
<br />o
<br />etc,)ISpecify) White
<br />M
<br />D
<br />Victor Lambrecht
<br />14a. USUAL OCCUPATION (Give kind of work done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />-111
<br />o
<br />Elementary or Secondary 10 -12) - College 11 -4 or 5.1
<br />n
<br />CA
<br />-717
<br />12
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />`,r
<br />ry
<br />°
<br />19a. INFORMANT - NAME
<br />IYes. no. oorr unk.) (11 yes. give war and dates of services)
<br />Victor Lambrecht
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />14590 S. Prosser Road Wood River, Nebraska 68883
<br />20. EM L R - SIGNATURE 8 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />- ..-!` 1240
<br />X
<br />❑ Burial ❑ Removal
<br />Apr 2, 2004
<br />Wood River Cemetery
<br />22a. FUNERAL HOME - NAV
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel Funeral Home
<br />❑ Cremation ❑ Donation
<br />Wood River, Nebraska 68883
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />411 West 11th St. P.O. Box 126 Wood River, Nebraska 68883
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. M. AND (c)) Interval between onset and death
<br />I
<br />PART �
<br />a, ( of! lung
<br />O
<br />(h) I
<br />1
<br />D
<br />r_ n
<br />CD
<br />7
<br />F-�
<br />CD
<br />CC)
<br />o
<br />�..
<br />Q
<br />C
<br />��
<br />O
<br />WHEN THIS COPY CARII S THE RAISED SEAL OF THE NEBRASKA HEAL 7; iM11, 0i SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL LFCORD i©N FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL $TIP 0170N, WHICH is
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />0OT�
<br />4/13/2004 2004041,94 OPAR
<br />- gSS /3�1AFT�'A'1���GiSTRNR
<br />LINCOLN, NEBRASKA HEALTWAND � SYS YI
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN 399WC2 AN AND SUPPORT 03853
<br />CERTIFICATE OF DEATH _ 04
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH (Month. Day. Year)
<br />Karlene Emma Lambrecht
<br />Female
<br />March 29, 2004
<br />a. CITY AND STATE OF BIRTH til not in U.S.A.. name country/
<br />Sa. AGE -Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH tMonlh. Day. Year)
<br />Sb. NOS. DAYS
<br />Sc. HOURS' MINIS.
<br />Grand island, Nebraska
<br />(Ym.l 62
<br />August 20, 1941
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. 'PLACE OF DEATH
<br />M
<br />© ❑
<br />505-54-4289
<br />HOSPITAL Inpatient OTHER: Nursing Home
<br />261, PLACEOF. INJURY -At home, farm. street. factory
<br />oflfllce bwlding. etc. /Specify)
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY - Name /N nol institution, give street and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other ( Specify,
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island, 68801
<br />Yes ❑x No ❑ i
<br />Hall
<br />9a. RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER ilnciuding Zip Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Wood River
<br />14590 S. Prosser Road 68883
<br />Yes ❑ No
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian, Mexican, German, etc)
<br />' 2. [N MARRIED F-1 WIDOWED
<br />13. NAME OF SPOUSE (If wile. give maiden name)
<br />etc,)ISpecify) White
<br />(Specify) Danish /German
<br />NEVER DIVORCED
<br />Victor Lambrecht
<br />14a. USUAL OCCUPATION (Give kind of work done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION
<br />(Specify only highest grade completed)
<br />Elementary or Secondary 10 -12) - College 11 -4 or 5.1
<br />of workmglile, evenilretir`F omemaker
<br />�j
<br />Own home
<br />-717
<br />12
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Karl Opp
<br />Colene Andersen
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />IYes. no. oorr unk.) (11 yes. give war and dates of services)
<br />Victor Lambrecht
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />14590 S. Prosser Road Wood River, Nebraska 68883
<br />20. EM L R - SIGNATURE 8 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />- ..-!` 1240
<br />X
<br />❑ Burial ❑ Removal
<br />Apr 2, 2004
<br />Wood River Cemetery
<br />22a. FUNERAL HOME - NAV
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel Funeral Home
<br />❑ Cremation ❑ Donation
<br />Wood River, Nebraska 68883
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />411 West 11th St. P.O. Box 126 Wood River, Nebraska 68883
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. M. AND (c)) Interval between onset and death
<br />I
<br />PART �
<br />a, ( of! lung
<br />DUE TO, OR AS A CONSEQUENCE Of- I Interval between onset and d
<br />(h) I
<br />i
<br />1
<br />DUE: I U. OH AS A UUNJtUUtivUt Ur: •• • _• °_• �_ ^ =� • ^ •�_ �__•
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />(Ages 10 -54) Yes Na
<br />Yes M No
<br />Yes No
<br />26a.
<br />261b. DATE OF INJURY /MO.. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW IN.;JRY OCCURRED
<br />Accident Undetermined
<br />M
<br />Suicide Pending
<br />Homicide Investigation
<br />26e. INJURY AT WORK
<br />yes ❑ No ❑
<br />261, PLACEOF. INJURY -At home, farm. street. factory
<br />oflfllce bwlding. etc. /Specify)
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />27a. DATFfOF DEATH IMo- Day. Yr.)
<br />211a. DATE SIGNED IMO.. Day. Yr)
<br />?.Sb TIME OF DEATH
<br />d -
<br />O
<br /><
<br />March 29, 2004
<br />sM
<br />27b. DATE SIGNED (MO Day Yr)
<br />2
<br />CC
<br />27c, TIME OF DEATH
<br />0.•M
<br />a < }
<br />W Z�
<br />z
<br />28c. PRONOUNCED DEAD /MO.. Day, Yr)
<br />28tl. PRONOUNCED DEAD (Hours
<br />M
<br />27 To the best of my knowledge. eat o u e at the time ate and place and due to the
<br />causelsl slated. �
<br />° ° ° 28e. On the basis of examination and,or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(sl stated.
<br />Signature and Titles ► 1
<br />(Si nature and Title) ►
<br />29. DID TOBACCO USE CONTRIBUTE TO HE�DEATH?
<br />❑ YES ❑ NO 1NKNOWN
<br />a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES I-le.
<br />30.b WAS CONSENT GRANTED?
<br />❑ YES al-10
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI (Type or Print)
<br />M.S. Copur, MD 2116 West Faidley Ave. Grand Island, NE 68803
<br />32a. REGISTRAR 7.
<br />&f ,',U X
<br />DATE FILED BY REGISTRAR (Mo.. Day. Yr.)
<br />APP -- 7 20Ut
<br />
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