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WHEN THUS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH A <br />SYSTEF4 IT CERTWES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL A <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />APR 7 2000 ASSISM <br />LINCOLN, NEBRASKA HEALTH AND h% <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEI <br />VITAL STATISTICS <br />If FRTTF1r.ATF OF DFATH <br />FANLEY S C-10-0- PM <br />STATE REGISTRAR <br />�`3�'STFJ4 <br />ftS FIIwiGE'k' 6,PORT <br />I DECEDENT NAME FIRST MIDDLE 'LAST <br />2 SEX <br />3. DATE OF DEATH /Month Day year) <br />Vern W. Niemoth <br />Male <br />April 4, 2000 <br />a CITY AND STATE OF BIRTH of not in USA name ccunlry; <br />5a AGE -last Binhtlay <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH ;MOnM. Dav year! <br />5b. MOS I DAYS <br />Sc. HOURS MINS <br />Rural Hall County, Nebraska <br />(Vrs.l <br />80 <br />February 28, 1920 <br />7 SOCIAL SECURTIY NUMBER <br />Ba. PLACE OF DEATH <br />HOSPITAL ❑ Inpatient OTHER ® Nurs,ng HOme <br />508 -30 -3737 <br />IN THE PAST 3 MONTHS' <br />❑ ER Outpatient ❑ Residence <br />Bb FACILITY - Name (If not insbtufion, give street and number) <br />Lakeview Nursing & Rehab Center <br />❑ DOA ❑ Othe "$peo "' <br />Etc . CITY TOWN OR LOCATION OF DEATH <br />Bid INSIDE CITY LIMITS <br />Be COUNTY OF DEATH <br />Grand Island <br />Yes ® No ❑ <br />Hall <br />9a RESIDENCE - STATE <br />9b COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d STREET AND NUMBER (Including Zip Codel <br />9e INSIDE CITY LIMITS <br />Nebraska I <br />Hall <br />Grand Island <br />716 S. Kimball 68801 <br />Yes ® Nc ❑ <br />10 RACE - (e.g.. White Black. American Indian <br />t 1 ANCESTRY Is g.. Italian. Mexican, German. etc) <br />12. ® MARRIED ❑ WIDOWED <br />13 NAME OF SPOUSE pl wde g w maiden name) <br />etc.) ISoeayl <br />White <br />(Specify) <br />American <br />NEVER DIVORCED <br />Inez Irene Loescher_ <br />28a DATE SIGNED (Mo.. Day. Yr 1 <br />MARRI <br />14. USUAL OCCUPATION (Give kino'ot work done during most <br />14b KIND OF BUSINESS INDUSTRY <br />15. EDUCATION <br />(Specily only highest grade completed) <br />Element ry Or Secondary 10.121 College 11 -n o' • i <br />8tI Grade <br />of working Me. even d rebred) <br />Grain Handling <br />Farmers Co -o <br />16 FATHER -NAME FIRST MIDDLE LAST <br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Walter N! oth <br />Erna Wiegert <br />18 WAS DECEASED EVER IN US AriMi -:f� FJRCES? <br />19a. INFORMANT - NAME <br />(Yes . ro . e' urk.; (If •:s. give — ai.d dates of services) <br />Yes WWII 1/16/42 - 12/30/45 <br />Inez Niemoth <br />19b INFORMANT MAILING ADDRESS SSTREET OR R.F.D NO. CITY OR TOWN. STATE. ZIP) <br />7 mb 11, Grand Island, Nebraska 68801 <br />20. ALMER - SIGNAT E IC NSE N 8-Y /,1 <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21 <br />c. CEMETERY OR CREMATORY . NAME <br />.� <br />X❑ Burial ❑ Rertwval <br />Apr. 6, 2000 I <br />Westlawn Memorial Park <br />22� FUNEitA OME -NAME <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Livingston- Sondermann F.H. <br />❑Cremation ❑Donation <br />Grand Island, Nebraska <br />i UN: HAi_riUr,. AUUHt , >n�ri tinny v ivv. �.'�' yr .v..r.. .,..a- a.• <br />i LnI 'KT T.1,.1 -.1. D--A it —A T-1 —A <br />23 V 1AR1IMMED TE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal Ibl. AND Icll <br />L {' Interval between onset and dear- <br />I <br />I z <br />� <br />pUE TO, OR AS A CONSEQUENCE OF <br />Interval between onset and oeatr. <br />DUE TO. OP- AS A CONSEQUENCE OF <br />Interval between onset and oeatn <br />Ic) <br />I <br />SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related P <br />ART III IF FEMALE. WAS THERE A 124 AUTOPSY <br />25, WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />IN THE PAST 3 MONTHS' <br />r EXAMINER OR CORONER , <br />(A2es 10 -54) Yes No Yes No <br />Yes D N. <br />26a <br />26b DATE OF INJURY (Mo.. Day <br />26c. HOUR OF INJURY <br />' 26d. DESCRIBE HOW INJURY OCCURRED <br />Accident Undetermined <br />7c <br />M <br />❑ Suicide 01 Pending <br />26e INJURY AT WORK <br />261. PLLAqCE OF INJURY - At home, farm. street. factory <br />26g. LOCATION STREET OR R.F.D. NO <br />CITY OR TOWN STATE <br />Homicide Investigation <br />yes ❑ No ❑ <br />otlice budding etc fSpeciy) <br />27a. DATE OF DEATH (Mo. Day. Yr) <br />28a DATE SIGNED (Mo.. Day. Yr 1 <br />28b TIME OF DEATH <br />April 4 2000 <br />231 <br />M <br />E N <br />27b DATE SIGNED IMo.. Day Yr.l <br />270 TIME OF DEATH <br />i ° <br />26c. PRONOUNCED DEAD (Mo. Day. yr) <br />28d. PRONOUNCED DEAD (Flourl <br />°g° <br />g� <br />} Aril 200 <br />f <br />6:30 am M <br />N a oz <br />,m, <br />M <br />27d To the best 01 my k weed death ggcunred at t tint date and place and due to the <br />20e On the basis of t my opinion death occurred at <br />examination and to ft <br />.° <br />° ° <br />t causelsi stated. /�, /V <br />caigaeisl <br />Me ema, date and Dlace and due to M1e causelsl <br />d place <br />stated. <br />(Si nature and Title) (��wv"'(f/ <br />(Si nature and Title <br />29 DID TOBACCO USE CONT UTE O THE DEATH? <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED <br />30.b WAS CONSENT GRANTED? <br />< YES ❑ UNKNOWN r� <br />❑ YES NO <br />❑ YES NO <br />31. NAME ND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( IType <br />a Prin <br />I Dr John A Wagoner MD 8 Alpha S:tre2L <br />Grand Islam <br />32a REGISTRAR <br />A"�_J <br />32b. DATE FILED BY REGISTRAR rilli Day. Yr) <br />20W <br />I <br />APR 6 <br />