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' Rev. ?1/97, <br />co Y i 3 <br />8 <br />C <br />2 <br />O <br />U <br />a <br />c <br />O <br />U <br />O <br />0) <br />E <br />cd <br />X <br />a) <br />co <br />Z <br />W <br />E <br />0 m <br />U <br />W <br />L <br />W a <br />0-0 <br />W a1 <br />m <br />Q O <br />Z LL <br />M <br />200405885 <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT <br />VITAL STATISTICS <br />rPPTTVTrATV nr nV A Tv <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />2. SEX 3. DATE OF DEATH /Month. Day. Year/ <br />Raymond Jake Luft <br />Male August 31, 2003 <br />4. CITY AND STATE OF BIRTH /ll not m USA.. name country) Sa. AGE - Last Birthday UNDER 1 YEAR <br />UNDER _1 DAY 6. DATE OF BIRTH /Month. Day. Year/ <br />(Yrs.) 84 5b. MOS. I DAYS <br />Clarks, Nebraska <br />So. HOURS' MINS. <br />C7 <br />February 21, 1919 <br />7. SOCIAL SECURTIY NUMBER Be. PLACE OF DEATH <br />507 -12 -8488 HOSPITAL: © <br />Inpatient OTHER: ❑ Nursing Home <br />Bb. FACILITY - Name [If not institution, give street and number] ❑ <br />ER Outpatient ❑ Residence <br />St. Francis Medical Center ❑ <br />DOA ❑ <br />Other[Specl1 -, <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />8d. INSIDE CITY LIMITS <br />8e, COUNTY OF DEATH <br />Grand. Island <br />Yes [3Q No ❑ <br />Hall <br />9a. RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER !including Zip Code] 9e, INSIDE CITY LIMITS <br />Nebraska Hall Grand Island <br />1813 N. Hancock, 68803 Yes ® No ❑ <br />10. RACE - (e.g., While. Black. American Indian. 11. ANCESTRY (e.g., Italian, Mexican. German, etc( 12. ❑ MARRIED <br />' etc.) Ispeci <br />® WIDOWED 13. NAME OF SPOUSE ll! wile. give maiden name/ <br />(Specify( <br />cAThite � American NEVER <br />DIVORCED <br />14a. USUAL OCCUPATION (Give kind of work done duringmost <br />of working lite, even if retired] <br />14b. KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specity only highest gratle completed( <br />Elementary og <br />r Reccndary 10 -121 Col lege n 4 or 5•I - <br />Farmer <br />Agriculture <br />16. FATHER -NAME FIRST MIDDLE LAST <br />17. MOTHER. <br />FIRST MIDDLE MAIDEN SURNAME <br />G. P. Luft <br />Ida Holtz <br />18. WAS DECEASED <br />EVER IN U.S. ARMED FORCES? <br />19a INFORMANT -NAME <br />(Yes. no. or unit) <br />pt yes. give war and dates of services( ' <br />No <br />I <br />Nadine Iversen <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE ZIP) <br />2908 West 17th St., Grand Island, NE 68803 <br />MB LIVER - SIGNATURE $ LICENSE N0. 1/13 21 a METHOD OF DISPOSITION 21 b. DATE <br />21c. CEMETERY OR CREMATORY NAME <br />®Burial ❑Removal Sept. <br />3, 2003 Westlawn Memorial Park <br />22a. FUNERAL ME - NAME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel - Butler- Geddes ❑Cremation ❑Donation <br />Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.O. NO.. CITY OR TOWN. STATE, ZIP) <br />1123 West Second, Grand Island, NE. 68801 -5809 <br />-- 23. IMMEDIATE CAI I.RF 1- 1- ...,.11 ..­ -__..... ..._. <br />PARTn _..._._..._...- ......�r -u <br />DUE TO, OR AS A CONSEQUENCE OF <br />(bt VNC�vvY�cv�� 5���v� I. vy\ �� �� cz P `� <br />DUE TO, OR AS A CONSEQUENCE <br />(d) <br />PART OTHER SIGNIFICANT ONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY <br />PREGNANCY IN THE PAST 3 MONTHS? <br />II J �\� (Ages; 10 -54) Yes No Yes No <br />26a. 26b. D��,AJJJTYE OF INJURY (Mo_ Daay.`YCJ 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED <br />7 Accident Undetermined M <br />❑ Suicide Pendin 26 INJURY AT <br />mterval between onset and death <br />I Interval between onset and death <br />I <br />I <br />Interval between onset and death <br />I <br />I <br />25. WAS CASE REFERRED TO MEDI( <br />EXAMINER OR CORONER' ( <br />Yes I I No XI <br />g e. WORK 261. P�,ACh QI�%t Je RY �cl hole, farm, street. Iactory 269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />EJ Homicide Investigation yes ❑, No ❑ <br />27a. DATE OF DEATH (Mot. Day. Yr.) . - 28a. DATE SIGNED /Mo.. Day. Yr.) 28b. TIME OF DEATH <br />27b. DATE SIGNED (MO.. Day. Yr) j27c IME OF DEATH � a G } 28c. PRONOUNCED DEAD /Mo.. Day, Yr.) 28d. PRONOUNCED DEAD /Hourl <br />s =� M <br />27d. To the best of my knowledge. tlfo3cutre pal and place and due lot i v 28e. On the basis of examination andor investigation, in my opinion death occurred at <br />causelsl slated. ° E the time, date and place and due to the cause(s) stated. <br />(Si nature and Title( ► (Signature and Title 0. <br />29. 010 TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN 0 UE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? _ <br />YES ❑ NO ❑ UNKNOWN ❑ YES NO ❑ YES � NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) 'YYYl---- "'mill <br />Steven Hu_sen M.D. 2116 W. Faidley, Grand Island, NE. 68803 <br />32a. REGISTRAR 32b. DATE FILED BY REGISTRAR /Mo.. Day Yr.) <br />FOR VITAL STAT1 .qT1rc I ICC /- 1,.-11 .r <br />I HEREBY CERTIFY THAT THIS IS AN EXACT PHOTO -COPY OF THE ORIGINAL DEATH CERTIFICATE <br />FILED WITH THE BUREAU OF VITAL STATISTICS IN LINCOLN, NEBRASKA. <br />('6 PFEL -BUT - GEDDES FUNERAL HOME <br />l <br />