200404558 - Laserfiche WebLink

Browse

1. DECEDENT - NAME FIRST MIDDLE LAST X n n 3. DATE OF DEATH /Month. Day. Yearl Glean 0. Kuster Male November 5, 2003 4. CITY AND STATE OF BIRTH tdrot n U.S.A. name country) rn "f1 UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH tMontle Day. Yearl MOS. DAYS Sc. HOURS' MINS \ n = -� April 23 1913 7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER: Nursing Home 506 -42 -6485 n N ❑ ER Outpatient ❑ Residence CD Holmes Lake Manor ❑ DOA ❑ Other /Specrlyi 8c. CITY. TOWN OR LOCATION OF DEATH So. INSIDE CITY LIMITS Be. COUNTY OF DEATH Lincoln Y� 1 "2 ❑ I 9a RESIDENCE - STATE 9b. COUNTY '*1 9d. STREET AND NUMBER' tinc /udmgIZip Cede/ 9e INSIDE CITY LIMITS t o W O� -_3 z Yes IN No ❑ 10. RACE - (e.g., White. Black. American Indian. \ f� (7) ni 13. NAME OF SPOUSE (if wile. give maiden name) D OD O =3 14a USUAL OCCUPATION /Give kind of work done during most 14b. KIND OF BUSINESS INDUSTRY r a � Elementary or Secondary 10 -121 College 11 -4 or 5 -1 of working life, even if refired) Carpenter Lincoln Public Schools Cfl 16. FATHER -NAME FIRST MIDDLE LAST MOTHER FIRST MIDDLE MAIDEN SURNAME 117 John Kuster CID � 19a. INFORMANT - NAME (Yes. no. or unk.) (if yes. give war and dates of services) X0 Dr. Curtis Kuster 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP) 6430 Ponderosa Drive Lincoln, Nebraska 68510 20. EMB MER - SIGNATURE LICgblSg NO. 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME U' 0 Bunal ❑Removal Z Lincoln Memorial Park 22a F LINERAL HO NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Lincoln Memorial Funeral Horne ❑ Cremation ❑ Donation Lincoln Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) WHEN THIS COPY CAMMS TIE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. 01. AND (c)) - Interval between onset and death PART I C t �t c lit y I al y% DUE TO, OR AS A CONSEQUENCE OF I Interval between onset and Beam •[ c K v& U P1 t 4'1 SYSTEM IT CERTMS TIE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH DUE TO. OR AS A CONSEQUENCE OF: I Interval between onset and death I 1 I OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not re ed PART PART PREGNANCY III IF FEMALE. WAS THERE A IN THE PAST., MONTHS? 24 AUTOPSY THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS- SECTION, WHICH IS G 11 � �� Y ! Gct-C (Ages 10 -541 Yes No h Yes 0 No Yes No 26a. THE LEGAL DEPOSITORY FOR VITAL RECORDS 28c. HOUR OF INJURY W SCRIBE HOW INJURY OCCURRED Accident � Undetermined I,,t DATE OF ISSUANCE ANLEY & COOPER 200404558 Suicide Pending 26e. INJURY AT WORK D Q��JUURY (At ho11r8, farm. street factory 5S ayll 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Investigation 12/3/2003 �t. office ol6c Homicide Ves No ASSISTANT STATE REGISTRAR 27a. DATE OF DEATH Ma. Day. Yy 28a. DATE SIGNED (Ma. Day. YrI 26b. TIME OF DEATH LINCOLN, NEBRASKA - _ HEALTH AND HUMAN -SERVICES SYSTEM )yam //l �j7 M a > STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPP_ ORT 27b. DATE SIGN /Me.. Day. Yrl 27c. TIME OF DEATH 28c. PRONOUNCED DEAD IMO.. Day, Yr./ 28d. PRONOUNCED DEAD (Hour) Amended December 3, 2003 VITAL STATISTICS p 3 12643 CERTIFICATE OF DEATH gw ° o6 .. 27d. To the best of my knowledge. death occurred at trle time, tiara and dace and due to the 28e. On the basis of examination ardor investigation, in my opinion death occurred at 1. DECEDENT - NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH /Month. Day. Yearl Glean 0. Kuster Male November 5, 2003 4. CITY AND STATE OF BIRTH tdrot n U.S.A. name country) Sa. AGE -Last Birthday I UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH tMontle Day. Yearl MOS. DAYS Sc. HOURS' MINS Hickman, Nebraska (Yrs. Sb. -9- 90 April 23 1913 7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER: Nursing Home 506 -42 -6485 ❑ ER Outpatient ❑ Residence 8b. FACILITY - Name (lt rot nstdudon, give street and number) Holmes Lake Manor ❑ DOA ❑ Other /Specrlyi 8c. CITY. TOWN OR LOCATION OF DEATH So. INSIDE CITY LIMITS Be. COUNTY OF DEATH Lincoln Y� 1 "2 ❑ Lancaster 9a RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER' tinc /udmgIZip Cede/ 9e INSIDE CITY LIMITS Nebraska Lancaster Lincoln 6101 Normal Blvd. 6851 Yes IN No ❑ 10. RACE - (e.g., White. Black. American Indian. 11. ANCESTRY (e.g.. Italian, Mexican, German, etc) 12. ❑ MARRIED j-] WIDOWED 13. NAME OF SPOUSE (if wile. give maiden name) etcyl I tie (Specify) ^^mnian Ve NEVER F-1 DIVORCED 14a USUAL OCCUPATION /Give kind of work done during most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Speciy Doty highest grade completed) Elementary or Secondary 10 -121 College 11 -4 or 5 -1 of working life, even if refired) Carpenter Lincoln Public Schools 12 16. FATHER -NAME FIRST MIDDLE LAST MOTHER FIRST MIDDLE MAIDEN SURNAME 117 John Kuster Anna Heupel 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT - NAME (Yes. no. or unk.) (if yes. give war and dates of services) X0 Dr. Curtis Kuster 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP) 6430 Ponderosa Drive Lincoln, Nebraska 68510 20. EMB MER - SIGNATURE LICgblSg NO. 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME 11A L. 1328 0 Bunal ❑Removal 11 -7 -2003 Lincoln Memorial Park 22a F LINERAL HO NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Lincoln Memorial Funeral Horne ❑ Cremation ❑ Donation Lincoln Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 6800 South 14 St. Lincoln, Nebraska 68512 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. 01. AND (c)) - Interval between onset and death PART I C t �t c lit y I al y% DUE TO, OR AS A CONSEQUENCE OF I Interval between onset and Beam •[ c K v& U P1 t 4'1 (b) I DUE TO. OR AS A CONSEQUENCE OF: I Interval between onset and death I 1 I OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not re ed PART PART PREGNANCY III IF FEMALE. WAS THERE A IN THE PAST., MONTHS? 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER? G 11 � �� Y ! Gct-C (Ages 10 -541 Yes No h Yes 0 No Yes No 26a. 26b. DATE OF INJURY (Mo.. Day Yr.) 28c. HOUR OF INJURY W SCRIBE HOW INJURY OCCURRED Accident � Undetermined I,,t Suicide Pending 26e. INJURY AT WORK D Q��JUURY (At ho11r8, farm. street factory 5S ayll 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Investigation ❑ ❑ �t. office ol6c Homicide Ves No 27a. DATE OF DEATH Ma. Day. Yy 28a. DATE SIGNED (Ma. Day. YrI 26b. TIME OF DEATH )yam //l �j7 M a > a ° } 27b. DATE SIGN /Me.. Day. Yrl 27c. TIME OF DEATH 28c. PRONOUNCED DEAD IMO.. Day, Yr./ 28d. PRONOUNCED DEAD (Hour) to It 7� 1 I 8� gw ° o6 .. 27d. To the best of my knowledge. death occurred at trle time, tiara and dace and due to the 28e. On the basis of examination ardor investigation, in my opinion death occurred at causes) stated • - ° a the time, date and place and due to the cause(s) stated. r (Signature and Title P. ^'� (Signature and Tide) ► 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CON IDERED? 30.b WAS CONSENT GRANTED? �[ ❑ YES NO ❑ UNKNOWN ❑ YES NO 1. ❑ YES NO 7� 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICLA OR COUNTY ATTORNEY( tType or point) Scott C. Rasmussen M.D. 3901 Pin 32a REGISTRAR 7 - BYNOV 10 2003 r�( re.✓ f i y. > South Half of the Northwest Quarter of Section 13, Township 11 North, Range 12 East of the 6`' P.M., Hall County, Nebraska.