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WWN THIS COPY CARRE:S THE RAISED SEAL "OF.THE NEBRASKA HEALTHAIIIPMft I 8WVICES;
<br />SYSY04 lT CERTMS THE BELOW TO BE rCZSCS0ftPyTEKVITALSTA OF THE ORIG/NAt: � 4N FX9 WM*F THE NEBRASKA HEALTH AND HUMAN SE THE LEGAL DEPOSITORY FOR VITAL REC . _
<br />DATE OF ISSUANCE
<br />3/30/2004 anrLEYSc
<br />200405359 At�TAfA.&R
<br />LINCOLN, NEBRASKA HEAL THAND SFRVECE S1�STb* ;
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN S 3tV - ICEAN¢ SUVO.RT fr:
<br />CERTIFICATE OF DEATH = _ 4 03461
<br />1. DECEDENT -NAME FIRST
<br />MIDDLE LAST
<br />2a AUTOPSY
<br />2. SEX -'
<br />DATE OF DEATH /Month. Day. Year)
<br />Otto John
<br />Mehl
<br />20. EMBALMER - SIGNATURE & LICENSE NO.
<br />Male
<br />March 21, 2004
<br />4. CITY AND STATE OF BIRTH !It rrot in U.S.A.. name country)
<br />Yes No
<br />Sa. AGE - Last Birthday I
<br />UNDER 1
<br />YEAR
<br />T
<br />n
<br />=
<br />2004
<br />Me.) 89
<br />5b. MOS. I
<br />DAYS
<br />5c. HOURS' MINS.
<br />October 8, 1914
<br />7. SOCIAL SECURTIY NUMBER
<br />Apfel- Butler - Geddes
<br />8a. PLACE OF DEATH
<br />z
<br />-
<br />514 -05 -5402
<br />Balko, Oklahoma
<br />tt22S ITAL
<br />--
<br />❑ Inpatient OTHER,
<br />❑ ER Outpatient
<br />❑ Nursing Home
<br />a Residence
<br />lI
<br />Sb. FACILITY - Name ( riot msNubort, give street and number)
<br />Home: 1121 W. 6th St.
<br />27a. DATE OF DEATH /Mo.. Day. Yr.)
<br />D
<br />❑ Other tSpecdv,
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />='
<br />Grand Island
<br />>=
<br />m
<br />a�w
<br />rn
<br />M
<br />cn
<br />9b. COUNTY
<br />280. PRONOUNCED DEAD (Mo.. Day, Yr.)
<br />9c. CRY. TOWN OR LOCATION
<br />w
<br />°�
<br />17 Cri
<br />O
<br />Hall
<br />d6�
<br />Grand Island
<br />1121 W.
<br />N
<br />Yes © No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g..
<br />Italian. Mexican, German, etc)
<br />40 -j
<br />® WIDOWED
<br />13. NAME OF SPOUSE tl1 wife. give makAvl name)
<br />\
<br />(��)
<br />German
<br />NEVER
<br />DIVORCED
<br />v
<br />14a. USUAL OCCUPATION /Give kindot wortk oboe dwir� mast
<br />working /rte, even ifrehred) Sell Emp toyed
<br />14b. KIND OF BUSINESS INDUSTRY
<br />M
<br />N
<br />15. EDUCATION
<br />\�
<br />Elementay or SeCOCgary 10 -121 College 11 -4 or 5�1
<br />1102 '?F
<br />of
<br />Concrete Contractor
<br />- -
<br />Construction
<br />16. FATHER -NAME FIRST MIDDLE
<br />LAST
<br />17. MOTHER
<br />FIRST
<br />MIDDLE MAIDEN SURNAME
<br />o
<br />Mehl
<br />Carrie
<br />Wahl
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />c
<br />N
<br />00
<br />CD
<br />O
<br />O
<br />No
<br />Gary Mehl
<br />A
<br />O
<br />\\
<br />o
<br />3
<br />r A
<br />c
<br />C-3
<br />W
<br />D
<br />C_n
<br />CD
<br />CD
<br />co
<br />Ca
<br />z
<br />Lot 5, Block 18, Wallich's Addition,
<br />Hall County, Nebraska
<br />O
<br />WWN THIS COPY CARRE:S THE RAISED SEAL "OF.THE NEBRASKA HEALTHAIIIPMft I 8WVICES;
<br />SYSY04 lT CERTMS THE BELOW TO BE rCZSCS0ftPyTEKVITALSTA OF THE ORIG/NAt: � 4N FX9 WM*F THE NEBRASKA HEALTH AND HUMAN SE THE LEGAL DEPOSITORY FOR VITAL REC . _
<br />DATE OF ISSUANCE
<br />3/30/2004 anrLEYSc
<br />200405359 At�TAfA.&R
<br />LINCOLN, NEBRASKA HEAL THAND SFRVECE S1�STb* ;
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN S 3tV - ICEAN¢ SUVO.RT fr:
<br />CERTIFICATE OF DEATH = _ 4 03461
<br />1. DECEDENT -NAME FIRST
<br />MIDDLE LAST
<br />2a AUTOPSY
<br />2. SEX -'
<br />DATE OF DEATH /Month. Day. Year)
<br />Otto John
<br />Mehl
<br />20. EMBALMER - SIGNATURE & LICENSE NO.
<br />Male
<br />March 21, 2004
<br />4. CITY AND STATE OF BIRTH !It rrot in U.S.A.. name country)
<br />Yes No
<br />Sa. AGE - Last Birthday I
<br />UNDER 1
<br />YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH tMonM. Day. Year)
<br />Rural Balko, Oklahoma
<br />2004
<br />Me.) 89
<br />5b. MOS. I
<br />DAYS
<br />5c. HOURS' MINS.
<br />October 8, 1914
<br />7. SOCIAL SECURTIY NUMBER
<br />Apfel- Butler - Geddes
<br />8a. PLACE OF DEATH
<br />❑Orman ❑Donation
<br />-
<br />514 -05 -5402
<br />Balko, Oklahoma
<br />tt22S ITAL
<br />--
<br />❑ Inpatient OTHER,
<br />❑ ER Outpatient
<br />❑ Nursing Home
<br />a Residence
<br />lI
<br />Sb. FACILITY - Name ( riot msNubort, give street and number)
<br />Home: 1121 W. 6th St.
<br />27a. DATE OF DEATH /Mo.. Day. Yr.)
<br />❑ DOA
<br />❑ Other tSpecdv,
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />� -U+
<br />Grand Island
<br />>=
<br />Yea © ND ❑
<br />a�w
<br />Hall
<br />M
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />280. PRONOUNCED DEAD (Mo.. Day, Yr.)
<br />9c. CRY. TOWN OR LOCATION
<br />w
<br />9d. STREET AND NUMBER f1ricluding Zip Code/
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />d6�
<br />Grand Island
<br />1121 W.
<br />6th St. 68801
<br />Yes © No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g..
<br />Italian. Mexican, German, etc)
<br />12. ❑ MARRIED
<br />® WIDOWED
<br />13. NAME OF SPOUSE tl1 wife. give makAvl name)
<br />etc.)(Specjflyr lte
<br />(��)
<br />German
<br />NEVER
<br />DIVORCED
<br />v
<br />14a. USUAL OCCUPATION /Give kindot wortk oboe dwir� mast
<br />working /rte, even ifrehred) Sell Emp toyed
<br />14b. KIND OF BUSINESS INDUSTRY
<br />(S nature and Title - # L
<br />15. EDUCATION
<br />ISpecily only highest grade completed)
<br />Elementay or SeCOCgary 10 -121 College 11 -4 or 5�1
<br />1102 '?F
<br />of
<br />Concrete Contractor
<br />- -
<br />Construction
<br />16. FATHER -NAME FIRST MIDDLE
<br />LAST
<br />17. MOTHER
<br />FIRST
<br />MIDDLE MAIDEN SURNAME
<br />Fred S.
<br />Mehl
<br />Carrie
<br />Wahl
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yes. no. or unk.) (H yes. give war and dates of services)
<br />No
<br />Gary Mehl
<br />19D. INYUHMANI MAILINU AUUHEJD
<br />lb I HtCI UM-U. NU., UI I T UK I UWN. b I A I t. GIYI
<br />2a AUTOPSY
<br />2517 Cottonwood Rd.,
<br />Grand Island,
<br />NE. 68801
<br />20. EMBALMER - SIGNATURE & LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE
<br />Yes No
<br />21c. CEMETERY OR CREMATORY NAME -
<br />�y� 'r/32s
<br />26c. HOUR OF INJURY
<br />El Biaial ❑Removal
<br />Accident F-1 Undetermined
<br />March 24,
<br />2004
<br />Balko Mennonite Brethren
<br />22a. FUNERAL POME -NAME
<br />M
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler - Geddes
<br />�At hollle. farm. street. factory
<br />26f. PLAB bulltlirIN
<br />b .Itli
<br />❑Orman ❑Donation
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />Balko, Oklahoma
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN.
<br />STATE, ZIP)
<br />1123 West Second, Grand Island, NE.
<br />68801
<br />27a. DATE OF DEATH /Mo.. Day. Yr.)
<br />23. IMMEDIATE CAUSE (EN I EH ONLY ONE CAU5E PEN LINE I-UH lal. (D), AND (C)) I Interval between onset and death
<br />PART CARDIAC ARREST :IMMEDIATE
<br />fat I
<br />DUE TO, OR AS A CONSEQUENCE OF. I Interval between onset and death
<br />I
<br />(b)
<br />I
<br />DUE TO. OR AS A CONSEQUENCE OF' I Interval between onset and death
<br />let
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related I PART
<br />III IF FEMALE. WAS THERE A
<br />2a AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />II
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />(Ages 10 -541 Yes No
<br />Yes No
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY (Ma. Day. Yr(
<br />26c. HOUR OF INJURY
<br />28d. DESCRIBE HOW INJURY OCCURRED
<br />Accident F-1 Undetermined
<br />M
<br />Suicide F-1 Pending
<br />26e. INJURY AT WORK
<br />�At hollle. farm. street. factory
<br />26f. PLAB bulltlirIN
<br />b .Itli
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />o6icc at. specal'1
<br />27a. DATE OF DEATH /Mo.. Day. Yr.)
<br />28a. DATE SIGNED tMa. Day. Yr.)
<br />28b. TIME OF DEATH
<br />� -U+
<br />7:00 A
<br />>=
<br />a�w
<br />.3-� j
<br />M
<br />27b. DATE SIGNED (Mo.. Day. Yr)
<br />27c. TIME OF DEATH
<br />280. PRONOUNCED DEAD (Mo.. Day, Yr.)
<br />28d. PRONOUNCED DEAD (Hour)
<br />w
<br />r
<br />ZC>
<br />d6�
<br />M
<br />3 -21 -2004
<br />11:0 A M
<br />s
<br />s �
<br />27d. To the best of my knowledge. death occurred at the time, date and place and due to the
<br />28e. On the basis of examination and,or investigation, id my opinion death occurred at
<br /><
<br />i2 v
<br />causefs) stated.
<br />v
<br />Hie time, date and piece and due to the causal -1 stated.
<br />(Si nature and Title 1,
<br />(S nature and Title - # L
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN
<br />CONSIDERED?
<br />30.b WAS CONSENT GRANTED? -
<br />❑ YES ❑ NO 1i UNKNOWN
<br />❑ YES 11
<br />NO
<br />❑ YES ❑X NO
<br />! 11. NA MI, ANU AUUHESb UI- "K I INEN I YH T bUM, 1"'UNEH b TN WN UH UUUN I T Al IUHNET I "We d!Trop
<br />SGT. V I T E RA ,GRAND ISLAM 'PObI E DEPARTMEi�T, 1 SOUTH LOMST STREET, GRAND ISL M, NE 68801
<br />32a. REGISTRAR FY At 4o w.a 32b. DATE FILED BY REGISTRAR (Mo-Day. Yr.)
<br />S
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