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1 <br />t <br />1 <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE DEPARTMENT OF HEALTH, <br />IT CERTIFIES THE BELOW TORE A TRUE COPY OF AN ORIGINAL RECORD-09CF/LE vow THE STATE <br />DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH IS E AL DbPOSfT�RY FOR <br />VITAL RECORDS. -- _- <br />DATE OF ISSUANCE _ _ " vat <br />JUL 12 1995 200315358 _ _ 4T Y'S. COOPER <br />ASSPSTANT STATE REGISTRAR <br />LINCOLN, NEBRASKA NEBRASKA BE_PAR#M&&OF_AALIN <br />STATE OF NEBRASKA - DEPARTMENT HEALTH <br />BUREAU OF VITAL STATISTIOS _ 200406358 <br />f� <br />CERTIFICATE OF DEATff = <br />--- `• - -••- ^ mom rinoi MIDDLE LAST <br />2 SEX 3. DATE OF DEATH /MOnm Oak Year) <br />Carl Arthur Martin Hoffer <br />Male June 29, 1995 <br />4 CITY AND STATE OF BIRTH a /noln USA namecounlryi 5a AGE - Last Birthday UNDER 1 YEAR <br />UNDER t DAY 6. DATE OF BIRTH ,Malin. Dar Year' <br />Reliance, South Dakota IYrs1 78 50 MOS DAYS <br />Sc HOURS MINS <br />O <br />7 SOCIAL SECURTIY NUMBER <br />March 20, 1917 <br />$wade PenOing <br />❑❑ <br />as PLACE OF DEATH <br />261 PLACE QF URY -Ate/ farm. street factory <br />office Ma1dI etc / <br />1 506-12-7770 <br />HOSPITAL In OTHER ❑ Nursing Home <br />® ER Outpatient ❑ Residence <br />8b FACILITY Name (N riot,nstnurron, give sheer and number/ <br />Mary Lanning Memorial Hospital <br />❑ DOA 11 spe ey <br />_ <br />81 <br />Bc CITY TOWN OR LOCATION OF DEATH Eld INSIDE CITY LIMITS El COUNTY OF DEATH <br />Hastings Yes ® No ❑ Adams <br />28a DATE SIGNED /Mo. Day Y„ 28b TIME OF DEATH <br />9a RESIDENCE -STATE 90 COUNTY 9c CITY TOWN OR LOCATION <br />9d STREET AND NUMBER 'Inoud, Cpdel <br />ng Zio 9e WSIDE CITY LIMIT$ <br />Nebraska Hall Grand Island <br />10 RACE <br />228 N. Ruby, 68803 Yesj] No ❑ <br />a le g. White. Black American InOlan i 1. ANCESTRY leg dalian Me.�can, German, eta t2 ®MARRIED <br />etC.l I$oecAy 15pe <br />❑ WIDOWED 13 NAME OF SPOUSE d/ wee qwe ma�oe, name' <br />ifyl <br />White American NEVER <br />MARRI <br />DIVORCED Pauline P. Reimers <br />isa USUAL OCCUPATION /Gne kind o /work done dwvg most 14b KIND OF BUSINESS INDUSTRY <br />d wwk,ng',le. even a reaed/ <br />15 EDUCATION IS peaty orxv nignesl grace completetl. <br />Owner /0 erator <br />P Car et Service <br />Elementary or Seconoary 10121 Cdkge t ao o•, <br />16 FATHER NAME FIRST MIDDLE LAST t' MOTHER <br />8 <br />FIRST MIDDLE MAIDEN SURNAME <br />Jacob Hoffer I <br />18 WAS DECEASED <br />Eva Schaffer <br />EVER IN US ARMED FORCES? �� / 12 / 194 2 t9a INFORMANT - NAME <br />(Yes no o, unk.) I" <br />St. Joseph Hastings, Nebraska 68901 <br />w dates <br />as gwe war and das of servq <br />Yes World War II 11 13 1945 P 1' Hoffer <br />19D INFORMANT MAILING ADDRESS (STREET OR R.F D NO.. CITY OR TOWN. STATE. ZIP) <br />[32a <br />Aif& Aid �. - <br />228 N. Ruby Ave. Grat@ Island, Nebraska 68803 <br />JUL 101995 <br />M R- SIGNAT NS 21a METHOD OF DISPOSITION 21b DATE <br />��1194 <br />21c CEMETERY OR CREMATORY NAME <br />X❑Burial El Removal 07/03/1995 Grand Island Cit Cemetery <br />22a FUNERAL HOME - NAME <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />A fel- Butler- Geddes ❑DOn" <br />Funeral Ho ellCremattm <br />Grand Island Nebraska <br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) <br />1123 West Second Grand Island Nebraska 68801 -5899 <br />23 IMMEDIATE USE IENTER ONLY ONE CAUSE PER I INF FOR— u., eun <br />I nfal <br />DUE TO. OR <br />fbl <br />DbF-10. OR <br />OF <br />��nm vas uerween onset and deal, <br />I <br />Interval between onset ­­and <br />I <br />- - - - -- - Interval between onset and deam <br />(CI <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death letl <br />PART <br />PART III I F FEMALE. WAS THERE A 2a AUTOPSY 25 WAS CASE REFERRED TO MEDICAL <br />PREGNANCY IN THE PAST 3 MONTHS'/ :ORONER> <br />Er""ol <br />26a 26b DATE OF INJURY /41, Day. Yc/ OF INJURY <br />(Ages 10 -541 Yes No YNo <br />26d. DESCRIBE HOW INJURY OCCURRED <br />7 Accident El Undetermined <br />- <br />M <br />$wade PenOing <br />❑❑ <br />26e INJURY AT WORK <br />261 PLACE QF URY -Ate/ farm. street factory <br />office Ma1dI etc / <br />26g LOCATION STREET OR R.F.D NO. CITY OR 70wN STATE <br />Homicide Investigation <br />yes (,lp ❑ <br />27a DATE OF DEATH (Mo Day Yr) <br />28a DATE SIGNED /Mo. Day Y„ 28b TIME OF DEATH <br />June 29, 1995 <br />$� 27b DATE SIGNED /Ab Day Yr) 27c TIME OF DEATH <br />7 3 �S <br />a M <br />$ > < J 2& PRONOUNCED DEAD rMo Day Yr.' 280, PRONOUNCED DEAD (HOUr1 <br />�$° <br />8� <br />M <br />270 To If1e best my know am ccc red time. tl DI duet <br />causels) staletl. <br />8�p M <br />28e. On the basis of examination and a Ines ation, In m opinion death occurred at <br />° o <br />dle Ume. date and place and due to the carnelsi statetl <br />IS nature and Title)) /.' eture antl Tide <br />29 DID TOBACCO USE CONTRIBUTE T DEATH? 30.8 HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED'( 30.b WAS CONSENT GRANTED', <br />El jJ�E AT <br />❑ YES UNKNOWN <br />YES El NO <br />VES NO <br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYi f Type a Pnrn <br />Dr. John A. Beck, M.D. 715 N. <br />St. Joseph Hastings, Nebraska 68901 <br />REGISTRAR <br />32b DATE FILED BY REGISTRAR /Ab Day Y, / <br />[32a <br />Aif& Aid �. - <br />JUL 101995 <br />___w — <br />