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<br />WHEN THIS COPY CARMES THE RAISED SEAL OF THE NEBRASKA HEALTH AXb HUA64N SERVICES
<br />SYSTEM IT CERTIFES TIE: BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD-ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST"- is
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _
<br />A _:t . -- )f=
<br />DATE OF ISSUANCE
<br />10/27/2004 004106 44 ANLEYS.COOFFM
<br />A &ISTA� M_!G4%R W
<br />LINCOLN, NEBRASKA HEALTHAMQhVMAIfiS�`RVR € 1
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEkV'_'M J t -
<br />FII�!@AFI3�IP.�ORT �1 r n
<br />VITAL CF.RTIFT ATF. ()F TNRA i iT n Q I I Xl "1
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
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<br />Sa. AGE -Last Birthday
<br />UNDER 1
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<br />0 v
<br />n
<br />6. DATE OF BIRTH tMorift Day. Year)
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<br />7. SOCIAL SECUFMY NUMBER
<br />8a. PLACE OF DEATH
<br />WHEN THIS COPY CARMES THE RAISED SEAL OF THE NEBRASKA HEALTH AXb HUA64N SERVICES
<br />SYSTEM IT CERTIFES TIE: BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD-ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST"- is
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _
<br />A _:t . -- )f=
<br />DATE OF ISSUANCE
<br />10/27/2004 004106 44 ANLEYS.COOFFM
<br />A &ISTA� M_!G4%R W
<br />LINCOLN, NEBRASKA HEALTHAMQhVMAIfiS�`RVR € 1
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEkV'_'M J t -
<br />FII�!@AFI3�IP.�ORT �1 r n
<br />VITAL CF.RTIFT ATF. ()F TNRA i iT n Q I I Xl "1
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />Herbert Frederick Harder
<br />Male
<br />September 25, 2004
<br />4. CITY AND STATE OF BIRTH itlnof n U.S.A. name counhyl
<br />Sa. AGE -Last Birthday
<br />UNDER 1
<br />,v
<br />0 v
<br />n
<br />6. DATE OF BIRTH tMorift Day. Year)
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<br />5e. HOURS' MINS.
<br />C) -4
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<br />7. SOCIAL SECUFMY NUMBER
<br />8a. PLACE OF DEATH
<br />506 -42 -4279
<br />HOSPITAL
<br />- --
<br />Inpatient OTHER: Nursing Home
<br />❑ ❑
<br />❑ ER Outpatient ® Residence
<br />8b. FACILITY - Name /If not inshfufion, give street and number/
<br />410 East 8th
<br />❑ DOA ❑ Omer (Spealvl
<br />8c. CITY, TOWN OR LOCATION OF DEATH
<br />T
<br />uu
<br />1 -
<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 Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />M
<br />410 East 8th Street 68801
<br />Yes ® No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican, Gartman, etO
<br />a
<br />❑ WIDOWED
<br />13. NAME OF SPOUSE 11f wile. give maiden name)
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<br />3
<br />�"
<br />DIVORCED
<br />r n
<br />cn
<br />14a. USUAL OCCUPATION (Give kindof work dare durM most
<br />CD
<br />15. EDUCATION (Specify only highest grade completed)
<br />CD
<br />=
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<br />12
<br />1
<br />17. MOTHER
<br />GJ
<br />Cn
<br />1
<br />Ella Suehlson
<br />1Q WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />1ga. INFORMANT -NAME
<br />WHEN THIS COPY CARMES THE RAISED SEAL OF THE NEBRASKA HEALTH AXb HUA64N SERVICES
<br />SYSTEM IT CERTIFES TIE: BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD-ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST"- is
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _
<br />A _:t . -- )f=
<br />DATE OF ISSUANCE
<br />10/27/2004 004106 44 ANLEYS.COOFFM
<br />A &ISTA� M_!G4%R W
<br />LINCOLN, NEBRASKA HEALTHAMQhVMAIfiS�`RVR € 1
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEkV'_'M J t -
<br />FII�!@AFI3�IP.�ORT �1 r n
<br />VITAL CF.RTIFT ATF. ()F TNRA i iT n Q I I Xl "1
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH /Month. Day. Year)
<br />Herbert Frederick Harder
<br />Male
<br />September 25, 2004
<br />4. CITY AND STATE OF BIRTH itlnof n U.S.A. name counhyl
<br />Sa. AGE -Last Birthday
<br />UNDER 1
<br />YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH tMorift Day. Year)
<br />5b. MOS. I
<br />DAYS
<br />5e. HOURS' MINS.
<br />Cairo, Nebraska
<br />(Yrs.)
<br />63
<br />November 1, 1940
<br />7. SOCIAL SECUFMY NUMBER
<br />8a. PLACE OF DEATH
<br />506 -42 -4279
<br />HOSPITAL
<br />- --
<br />Inpatient OTHER: Nursing Home
<br />❑ ❑
<br />❑ ER Outpatient ® Residence
<br />8b. FACILITY - Name /If not inshfufion, give street and number/
<br />410 East 8th
<br />❑ DOA ❑ Omer (Spealvl
<br />8c. CITY, TOWN OR LOCATION OF DEATH
<br />8d. 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 Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />410 East 8th Street 68801
<br />Yes ® No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican, Gartman, etO
<br />12. MARRIED
<br />❑ WIDOWED
<br />13. NAME OF SPOUSE 11f wile. give maiden name)
<br />etc.( (Specify( White
<br />(specM) German
<br />NEVER
<br />DIVORCED
<br />Laberta Schweitzer
<br />14a. USUAL OCCUPATION (Give kindof work dare durM most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />of working life, even it retired!
<br />Forklift Operator
<br />Manufacturing
<br />Elementary a Secondary 10 -12) College 0-4 or 5 -I
<br />12
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />17. MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Herbert Harder
<br />Ella Suehlson
<br />1Q WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />1ga. INFORMANT -NAME
<br />(Yes. no. or unk.) (If yes. give war and dates of services)
<br />Yes 1 11/12/1957 - 11/11/60
<br />Laberta Harder
<br />410 East 8th Street Grand Island, Nebraska 68801
<br />20. EMBAL ��GN��ATUR LICENSE NO. a 21 a. METHOD OF DISPOSITION 21G DATE 21c. CEMETERY OR CREMATORY - NAME
<br />O Burial ❑ Removal Sep 28, 2004 Westlawn.Memorial Park
<br />22a. FUNERAL HOME - NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel - Butler- Geddes Funeral Home ❑ Cremation ❑ Donation Grand Island, Nebraska
<br />221b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, LP)
<br />1123 W. 2nd St. Grand Island, Nebraska 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. lb). AND (cO I Interval between onset and death
<br />PART
<br />f (al Gunshot to the head I immediate
<br />DUE TO, OR AS A CONSEQUENCE OF I Interval between onset and death
<br />(b) I
<br />DUE TO, OR AS A CONSEQUENCE OF I Interval between onset and death
<br />i
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions
<br />PART
<br />6
<br />28a. 26b. DATE OF INJURY (MO.. Day. Yr.J I 26c. HOUR OF INJURY
<br />xr
<br />Accident E] Undetermined Sept. 2 5, 2004 , p pr? 0:00
<br />Suicide [] . Pending 260. INJURY AT WORK 261. PLACE IF INJURY - At ho, , is
<br />1:1 ® dfice building, etc. /SpeCrryt
<br />aHomicide Investigation Yes No H n m P
<br />PART III IF FEMALE WAS THERE A 24 AUTOPSY 25, WAS CASE REFERRED TO MEDII
<br />PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER?
<br />(Ages 10 -541 Yes No D I Yes 0 No Yes No
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />url Gunshot to the head
<br />street. factory 26 LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />4 E. 8th, Grand Island, NE 68801
<br />278. DATE OF DEATH (Ma. Day. Yr.) 28a DATE SIGNED (Ma. Day. Yr.) 28b. TIME OF DEATH
<br />September 25, 2004 Q October 13, 2004
<br />M
<br />27b. DATE SIGNED (Md.. Day. Yr.) 27c. TIME OF DEATH � � } 28c. PRONOUNCED DEAD (Mo.. Day, Yr.) PRONOUNCED DEAD • (hburl
<br />a�
<br />M ¢ ~�
<br />Sept. 2 2004 3 :30 p
<br />$ # M
<br />e 27d. To the best of my knowledge. deem occurred at the time, dale and place and due to the ° kr 289. On the basis of a anon and ,or i gation, in mY nion death occurred at
<br />causes) stated. - ~ $ a me time, tlare an
<br />pl a and d eauselsl stated.
<br />(Signature and TKlel to (Signature and Title
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN C11SI11ED1 30.D O EN GRAN EDn
<br />❑ YES M NO ❑ UNKNOWN El YES ® NO ❑ Y ® NO
<br />31. NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) irvce or Prind
<br />
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