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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ����A',�'�1 X/'
<br />DATE OF ISSUANCE
<br />OCT 4 2000 200410168 ASSISTANT STALE REG SOTRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF IWF.ALTTI AND HUMAN SERVICES FINANCE AND SUPPORT
<br />MAT, STATIS TICS
<br />CERTIFICATE OF DEATH
<br />I 'If I F If NI NAMF FIRCI 111'1, 11f
<br />IASI
<br />? iFA
<br />7 11411 OF 1114111 IA1 nn I"" - -
<br />Charles Raymond
<br />Dittmar
<br />Male'
<br />September 23, 2000
<br />ar- my 1 S14tF OF pHT. .nrnl -tn- eue n�! .. -
<br />I
<br />l'sIR Ita,
<br />I /IDERI YCAn
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<br />IZ r� MARRI
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<br />Sc HOUR MINS
<br />White
<br />Brush, Colorado
<br />American
<br />78
<br />IN IIINY AF WrlR4
<br />JRI P`AI.E OF IN AIR AI home I.lnrr
<br />XX h..1nr
<br />September 11, 1922
<br />IfH IY NI)T,IH
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<br />RN(1 C1F DI7$IIJf -SS INDUSTRY
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<br />ACF OF DEATH
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<br />(construction)
<br />-72 -1132
<br />HOSPITAL [
<br />Inpatient OIIIFH [ , Nurainp llnrnn
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<br />FR DIIPAR.nI
<br />� R.s•dPnCC
<br />St. Francis Medical Center
<br />26a OAIE SIGNED Ime nav Y, t --- - - - -
<br />[]
<br />DOA
<br />�] OR,.r,s,.,1, /, ----------_---_"_-
<br />9r I1II TOWN OR L(N;n lt• "1N (R DEATH - -
<br />q.1
<br />INSIf1E CITY LIMITS RC C(JUNTY OF 1114TH
<br />"
<br />Island-
<br />TERRY L. LOSCHEN
<br />1_,P (gi 10 U�-
<br />_Grand_
<br />9a of S,OFflCE STAIF
<br />- --
<br />q_D COUNTY
<br />-- -- -
<br />0r (.11, TOWNORt(ICATION
<br />Nebraska
<br />fAq.s 10 541 Yes —� No
<br />H_all
<br />Grand Island__
<br />_
<br />10 PACF 1n 1 Wf0, Rllr4 Amn•ranlnd
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<br />11 AflfF IIIY
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<br />JRI P`AI.E OF IN AIR AI home I.lnrr
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<br />16 f ATHFR - NAME FIRST
<br />10101A
<br />F I n t
<br />I7 MOTHER
<br />Hall'
<br />prrr(uranq Im CMe/ I ge
<br />2324 W. John 68803 I Y., ICJ No ❑
<br />❑ WIDOWED 13 NAME Or SPOUSE /tt e•te maobn Hamel -
<br />- DIVORCED Phyllis Backsten -
<br />I S EDUCATION ISPerdY nnly nrgM4l pale cw+Pla{edl _-
<br />EIlm<11141y 0, Secondary 10 121 CONcf, IT 41, S I
<br />- -- 12
<br />MIUUI t
<br />Unknown Dittmar Maggie Davidson
<br />- - - -- -- -- - -- - -- - -_ --fig --- - - - - -- - -- - - - -
<br />t9 Y:nS OE CEASED EVER IN 11S ARMED (ONCE $' 9.t INF OTIMANT NAMF
<br />lYee w, r.unAl 'I"191.— A1.1dlma,lSPrvit'gtes unknow
<br />Yes _1Na�SeaBeesz WW_ I_I _ Phyllis Dittmar
<br />IuD INFORMANT MAI(ING ADDRESS rS,fIFF1 OR AI D N!1 CIIY OR IOWN STAIF ZIPI
<br />2324 West John, Grand Island, Nebraska 6_8803 _
<br />.6 EMRALMFR , R-,NAil!NF A I!(' ENSF. NI) 171.1 MF IHO(10f -7- ISP115111(NN �ZID HALE 71r (.FMFIFRY OR CRFMAI(/RY NAME
<br />Not Embalmed [ ]n "r A, []Ben A, Sept. 23, 2000 Central NE Cremation Servir
<br />- --- - - - - -- - --- - - - - -- - --- - - - - -- - -- - - -- — -
<br />27A rIINFRAIHOMF NAMF 214 CEMETERY OR CREMATORY LOCATION CRY Oft TOWN STATE
<br />Livingston F.H. [ (;n.,,,A,.- []Dena, 719 Front Street, Gibbon, Nebraska
<br />22b FUNERAL HOME ADDRESS tSIREET
<br />6.9.1 North Webb Road, Grand_ Island_, _Nebraska 68803
<br />2l %- IM _OI \(A /TE\TA�US,,E` / _!FIJI FBI ONI Y ONE CAUSE PFR LINE FOP IAl IDI. AND 1,11 IMrw�r b \,lw.srl 0n,el aM d.am
<br />PARI,I I V` C 1 V v _�- v-- - - - - -- -- - - - - -- - -- -- i -- m V' V 1 J _
<br />_ _I
<br />DUE TO OR A$ A CONSFOUPNCE OF ! InlerYa belw.e'I (NISa And nealn
<br />1
<br />(bl
<br />Olt/ IO Ofi a ; a /;Orl'if r)I R Nr; F. (X -- _ 1 Ireerodl 1)♦r'rNn Mt111 aM r1eaM
<br />Icl
<br />TERRY L. LOSCHEN
<br />25 WAS CASE REFERRED TO MEDICAL
<br />I. EXAMINER OR CORONER'
<br />OTNE R $IGNIF IC, ANI CONOIIN7IJ$ Cmddgvls r.Mllnbulvlq In ihP Aq.'IIh hul nPl rnulnd
<br />PART �� ^
<br />PART III If FEMALE WAS (HERE A
<br />PA" IN Tf1E PA$T]M(1NTHSn
<br />L IOPSY
<br />11 U-
<br />fAq.s 10 541 Yes —� No
<br />�NO
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<br />Y.S NO DQ
<br />Xh DATE OF IN,Il111Y (Aln na, r I
<br />1r 1111IR O1 IN.J RIY
<br />264 DESF:RIRF HOW INJURY OCCURRED
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<br />27a. DA1F OF DFAIR .AM Dar 1,1
<br />26a OAIE SIGNED Ime nav Y, t --- - - - -
<br />-- 26b RMF OF DEATH - -��-
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<br />7/b UATE$IrNEO t4b O.lr to
<br />2h )IMF OFDEADI
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<br />26c PRONOUNCED DEAD IMo DAKYf/
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<br />7(4 On Ote basis of exam-1, a11d o, nyeSl gal,on n m, Ogm- MaM Vied M
<br />nnfe And PIAre and due to Me caus.fsl Mated
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<br />ISrg!lawre and i Ilel ► _ _�C %��ur _ _ . _ _ \ \ \��
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<br />ISlgnature end T 1IeL ►
<br />'
<br />7q DID TI T {nCCO USE <:r)Ni NIRUiE IO THE NEAIH'
<br />YFt [, tl() tIN""-N
<br />70a tln (IIJ(iAN OR TISSUE DONATION R(EN f,ONSIDF REDT
<br />(_]
<br />-
<br />Job W FN
<br />A$CONSI (:RANIf U'
<br />YfS NO
<br />[] VCS NO
<br />J1 NAME ANO ADORE ;S OF CFIl IIF 1ER IpHV SICIAN, CON(1IJFR S p11V SICIAIJ
<br />OF! r:OUNTV Al fO11NF_YI
<br />11R ao, Y,qj
<br />J. J. Cannella, M. 729 N. Custer, Grand Island, NE 68803
<br />17a HF GISTRAR l2b DAfEFlLED8YRFG1'',IRA9 AIL, (tar NI
<br />t
<br />q tit, S E P 2 8 2000
<br />I hereby certify this to be a true and correct copypf the original
<br />filed with the State of Nebraska
<br />d1° by
<br />a
<br />Signed in my prese
<br />�s7'' d of'�
<br />Notary Public
<br />TERRY L. LOSCHEN
<br />*
<br />MY COMMISSION EXPIRES
<br />NOTARY..
<br />'•2 qp5. ",
<br />May 2, 2006
<br />
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