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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT QF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DMSI-TORY FOR
<br />VITAL RECORDS.
<br />-%=
<br />DATE OF ISSUANCE
<br />AN 1992 STANLEY � "_COOT'ER, DIRECTOR
<br />LINCOLN, NEBRASKA BUREAU =0F 7F-ITA -f ZV4 1STICS
<br />200408859 STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH .-Vr
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />24. AUTOPSY
<br />(Specify Yes a No)
<br />/��
<br />3. DATE OF DEATH (Month. Day. Year)
<br />Elmer Herman
<br />Knuth
<br />Male
<br />DESCRIBE HOW INJURY OCCURRED
<br />June 8, 1992
<br />4. CITY AND STATE OF BIRTH (a not m U.S.A. name counkyl
<br />5a. AGE - La-
<br />(Yra)
<br />YEAR
<br />UNDER
<br />1 DAY
<br />16, DATE OF BIRTH (Monts. Day. Year)
<br />5b. h10S.,il DAYS
<br />5c. HOURSi
<br />MINS,
<br />Dewey County, Oklahoma
<br />79
<br />DATE SIGNED (Mo., Day, Yr.)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (Mo.. Day, Yr.)
<br />October 23, 1912
<br />7. SOCIAL SECURITY NUMBER
<br />Ba. PLACE OF DEATH
<br />HOSPITAL ❑ Inp"eem ❑ ER /Outpaeem ❑ DOA
<br />508 -10 -2047
<br />I -1 QTHER: ❑ Nursing Home XResidence ❑ Other(SpeCily)
<br />v Bb. FACILITY - Name Is not Nadfulgn• give aaeef end number)
<br />BC. CRY, TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />( Speciy Yes or ft"
<br />Bs. COUNTY OF DEATH
<br />1115 W. Anna
<br />Grand Island
<br />Yes
<br />Hall
<br />v 9a RESIDENCE -STATE
<br />9D. COUNTY
<br />9c. CRY• TOWN OR LOCATION
<br />STREET AND NUMBER (Including Zip Code)
<br />9e. INSIDE CITY LIMITS
<br />/Specify Yea or Not
<br />Nebraska
<br />Hall
<br />Grand Island
<br />190.
<br />1115
<br />W. Anna 68801
<br />Yes
<br />10. RACE - le.g.. White. Beck American Indian,
<br />ANCESTRY le.g.,ltalian, Mexican. German, aft.) t2. MARRIED,NEVER MARRIED,
<br />WIDOWED. DIVORCED (Specify)
<br />t 3. NAME OF SPOUSE (a wile, give maiden namel
<br />ate.) ISpecdyl
<br />White
<br />111.
<br />!Specify)
<br />American OV Married
<br />Irene Boltz
<br />149. USUAL OCCUPATION /Gin* kind o, work dare during most
<br />Ida, even AroMedl
<br />14b. KIND OF BUSINESS INDUSTRY
<br />gglj
<br />Elementary a Secondsry 10 -12) I Cdega (1-4 a 5�1
<br />d waking
<br />Salesman /Driver aSq
<br />Weldin 530
<br />10th Grade
<br />18. FATHER - NAME FIRST MIDDLE
<br />LAST
<br />MOTHER -MAIDEN NAME
<br />FIRST MIDDLE UST
<br />Herman NMN Knuth
<br />117.
<br />Augusta
<br />NMN Matthiesen
<br />• 18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19. INFORMANT -NAME - MAILI NG ADDRESS
<br />(STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />(Yes, no, a unk) (B yes, give was and dates of services)
<br />No -- - - - - --
<br />Irene Knuth 1115 W. Anna Grand Island Ne. 68801
<br />20a. BURIAL, Cr ematlon,Rsnloval,
<br />20b. DATE
<br />20c. CEMETERY OR CREMATORY - NAME
<br />ZOd. LOCATION CITY OR TOWN STATE
<br />Donation
<br />urial
<br />ne 11, 1992
<br />Grand Island City Cemeter
<br />Grand Island Nebraska
<br />21. LMER - SIGNATU E LI SE , `�./
<br />22. FUNERAL HOME - NAME AND ADDRESS
<br />(STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP) 6880 1
<br />Livingston- Sondermann 505 W. Koenig, Grand Island, Ne.
<br />23. IMME T CAUSE INTER ONLY ONE CAUSE PER LINE FOR (al. lb), AND (c))
<br />I Interval between onset and death
<br />PART - _
<br />691 G�
<br />Z
<br />!/a L%1'�
<br />•'"
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />I Interval b9fliten onset and death
<br />i
<br />i
<br />Interval hotween onset and death
<br />OTHER SIGNIFICANT CONDITIONS - Condi Ions contributing to death but not related
<br />PART
<br />11
<br />PART III IF FEMALE, WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />Yes ❑ No ❑
<br />24. AUTOPSY
<br />(Specify Yes a No)
<br />/��
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />perry Yes or No)
<br />-
<br />26a. ACCIDENT. SUICIDE, HOMICIDE, UNDET.,
<br />28b. DATE OF INJURY (Mo.,Day. Yr.)
<br />26c. HOUR OF INJURY
<br />DESCRIBE HOW INJURY OCCURRED
<br />OR PENDING INVESTIGATION ( Specify)
<br />126d.
<br />26e. INJURY AT WORK
<br />(Specify, Yes or No)
<br />2&. PLACE OF INJURY - At home. farm, street factory.
<br />office building, etc. ISpecifyl
<br />26g. LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE
<br />L
<br />27a. DATE OF DEATH (MO.. Day. Yr.)
<br />j& i
<br />5
<br />28a. DATE SIGNED (Mo., Day. Yr)
<br />28D. TIME OF DEATH
<br />DATE SIGNED (Mo., Day, Yr.)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (Mo.. Day, Yr.)
<br />28d. PRONOUNCED DEAD Ihbur)
<br />�.
<br />r1b /r- t
<br />5 e
<br />p
<br />To the best of my knowledge, death occurred at time, date a ace and due to the
<br />l awed Y.
<br />(Si name and Tice �-+ •
<br />28e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time• date and place and due to the cause(s) stated.
<br />Si natu and Tito
<br />29a. DID TOBACCO USE CONTRIBUT THE DEATH?
<br />❑ YES O ❑ UNKN WN
<br />30a. H ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />O YES
<br />90b. WAS CONSENT GRANTED? _ /
<br />❑ YES �O
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICAN, CORONER'S PHYSICAN OR COUNTY ATTORNEY) (Type or Print)
<br />Gary Settj , 908 N. HOward Suit le 08, Grand Island, NE 68803
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.)
<br />r,
<br />- vIF0r-
<br />T
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