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Index against Lot Twenty (20), Belmont Addition to the City of Grand Island, Hal.
<br />County, Nebraska
<br />WHEN THIS COPY CARDS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN'SERNCES
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE6O1W,0N,FX Z*1TH,
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS CTi9]i M11"QRI IS"
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />r 3-
<br />DATE OF ISSUANCE
<br />10/19/2004 200410695 A 1- _
<br />LINCOLN, NEBRASKA HEALTH AND fKNNAN FCW3!`VS1EM_
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND.SUPPORT.
<br />VITAL STATISTICS _ 11228
<br />CERTIFICATE OF DEATH = �,
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX -
<br />1 DATE OF DEATH /Mont. Day. Year)
<br />Theodore (NMI) Martens
<br />Male
<br />October 6 2004
<br />4. CITY AND STATE OF BIRTH /dnotin U.S.A.. name country/
<br />be. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />C') cr;
<br />6. DATE OF BIRTH /Mont. Day. Yowl
<br />(Yrs.l 9 2 5b.
<br />MOS. DAYS
<br />5c. HOURS' MINIS.
<br />December 13 1911
<br />Alda, Nebraska
<br />,
<br />7. SOCIAL SECURTIV NUMBER
<br />Be. PLACE OF DEATH
<br />HOSPITAL: ❑ Inpat ent OTHER: ® Nursing Home
<br />508-05-5092
<br />❑ ER Outpabers ❑ Residence
<br />81b. FACILITY -Name /I/rotinsidufian, give street and number)
<br />Beverly Health Care -Park Place
<br />M N
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />1`
<br />Be. COUNTY OF DEATH
<br />z n
<br />Yes X❑ Ne ❑
<br />ry
<br />9a RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER /lncluM'ngZ1p Code/
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />C
<br />-� m
<br />10. RACE - (e.g., White. Black. American Indian.
<br />O
<br />12. a MARRIED ❑ WIDOWED
<br />13, NAME OF SPOUSE (a wile. give maiden name)
<br />etc.) (Specify)
<br />(Specify)
<br />American
<br />NEVER DIVORCED
<br />1 Elaine Wiese
<br />White
<br />M
<br />14a. USUAL OCCUPATION /Give kindo/ work dare during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />1
<br />(Specify only highest grade completed)
<br />Elementary a Secondary 10 -12) Cdlege 11 -4 a 5�1
<br />of working life, even it re6redl
<br />Laborer
<br />Farm E ui ment
<br />8
<br />16. FATHER -NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Otto Martens I
<br />Lena Scheel
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a INFORMANT - NAME - -
<br />r n
<br />>
<br />S
<br />No
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />04 Rub Ave., Grand Island, Nebraska 68801
<br />O
<br />(
<br />7j
<br />C/)
<br />1
<br />f -►
<br />(f
<br />® Burial ❑ Removal
<br />OL" tJober ll, 2004
<br />West 1 aw n Cemetery
<br />22a. FUNERAL HOME -NAME -
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />T
<br />❑c`ematon ❑Donation
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />23. IMMEDIATE CAUSE_ /� (ENTER ONLY ONE CAUSE PER LINE FOR tat. Ibl. AND (c) Interval between inset and death
<br />PART U fie,''`^ /��dJ /C /J I '
<br />I
<br />al
<br />DUE TO, OR AS A CONSEQUENCE OF I Interval between onset and death
<br />I
<br />I
<br />(b)
<br />DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and death
<br />I
<br />I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related P
<br />�+
<br />24 AUTOPSY
<br />tom- r-
<br />PART PREGNANCY
<br />O
<br />EXAMINER OR CORONER?
<br />II
<br />(Ages
<br />10 -54) Yes No
<br />Yes No X
<br />Yes No X
<br />26a.
<br />26b. DATE OF INJURY
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW IN, JRY OCCURRED
<br />❑ Accident ❑ Undetermined
<br />-r
<br />✓a
<br />❑ Suicide ❑ Pending
<br />26e. INJURY AT WORK
<br />EOa
<br />ddng UUR -Al hpm , )a rm. street. factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />El Homicide Investigation
<br />Yes ❑ No ❑
<br />Specal'
<br />CD
<br />27a. DATE OF DEATH (Mo.. Day. Yr.)
<br />28a DATE SIGNED (MO.. Day. Yr)
<br />28b. TIME OF DEATH
<br />October 6, 2004
<br />Y
<br />F-r
<br />C
<br />M
<br />$ 75
<br />27b. DATE SIGNE /MO.. y.�Y/r�./
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (MO.. Day, Yc)
<br />28d. PRONOUNCED DEAD (Fbud
<br />a J
<br />-�
<br />7 :19 P. M
<br />a <�
<br />¢_�
<br />°
<br />CJ I
<br />M
<br />27d. To the f my owledge. death occurrod time- date and place due to the
<br />2Be. On the basis of examination and,a investigation, in my opinion death occurred at
<br />cause(s) ted.
<br />v
<br />th e time, date and place and due to the cause(sl stated.
<br />z
<br />(Signature and Title)
<br />29, DID TOBACCO USE CONTRIBUTE TO THE TH? / }
<br />-a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 131
<br />WAS CONSENT GRANTED?
<br />❑
<br />❑ YES NO El UNKNOWN
<br />❑ YES p(I N0
<br />YES .. NO
<br />31 _ NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Gordon Hrnicek M.D. 729.4N. Custer Ave. Grand Island NE 68803
<br />32a. REGISTRAR
<br />n
<br />Index against Lot Twenty (20), Belmont Addition to the City of Grand Island, Hal.
<br />County, Nebraska
<br />WHEN THIS COPY CARDS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN'SERNCES
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE6O1W,0N,FX Z*1TH,
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS CTi9]i M11"QRI IS"
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />r 3-
<br />DATE OF ISSUANCE
<br />10/19/2004 200410695 A 1- _
<br />LINCOLN, NEBRASKA HEALTH AND fKNNAN FCW3!`VS1EM_
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND.SUPPORT.
<br />VITAL STATISTICS _ 11228
<br />CERTIFICATE OF DEATH = �,
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX -
<br />1 DATE OF DEATH /Mont. Day. Year)
<br />Theodore (NMI) Martens
<br />Male
<br />October 6 2004
<br />4. CITY AND STATE OF BIRTH /dnotin U.S.A.. name country/
<br />be. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH /Mont. Day. Yowl
<br />(Yrs.l 9 2 5b.
<br />MOS. DAYS
<br />5c. HOURS' MINIS.
<br />December 13 1911
<br />Alda, Nebraska
<br />,
<br />7. SOCIAL SECURTIV NUMBER
<br />Be. PLACE OF DEATH
<br />HOSPITAL: ❑ Inpat ent OTHER: ® Nursing Home
<br />508-05-5092
<br />❑ ER Outpabers ❑ Residence
<br />81b. FACILITY -Name /I/rotinsidufian, give street and number)
<br />Beverly Health Care -Park Place
<br />❑ DOA ❑ Other (Spec /tv,
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yes X❑ Ne ❑
<br />Hall
<br />9a RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER /lncluM'ngZ1p Code/
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />404 Ruby Ave. 68801
<br />Yes [j] No
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican. German, etc
<br />12. a MARRIED ❑ WIDOWED
<br />13, NAME OF SPOUSE (a wile. give maiden name)
<br />etc.) (Specify)
<br />(Specify)
<br />American
<br />NEVER DIVORCED
<br />1 Elaine Wiese
<br />White
<br />M
<br />14a. USUAL OCCUPATION /Give kindo/ work dare during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION
<br />(Specify only highest grade completed)
<br />Elementary a Secondary 10 -12) Cdlege 11 -4 a 5�1
<br />of working life, even it re6redl
<br />Laborer
<br />Farm E ui ment
<br />8
<br />16. FATHER -NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Otto Martens I
<br />Lena Scheel
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a INFORMANT - NAME - -
<br />(Yes. no. or unk.) (if yes. give war and pates of services)
<br />Elaine Martens
<br />No
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />04 Rub Ave., Grand Island, Nebraska 68801
<br />20.E LMER - SIG NA R LICE] O.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21
<br />c. CEMETERY OR CREMATORY NAME
<br />) # 10 71
<br />® Burial ❑ Removal
<br />OL" tJober ll, 2004
<br />West 1 aw n Cemetery
<br />22a. FUNERAL HOME -NAME -
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />All Faiths Funeral Home
<br />❑c`ematon ❑Donation
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />2929 S. Locust St., Grand Island, Nebraska 68801
<br />23. IMMEDIATE CAUSE_ /� (ENTER ONLY ONE CAUSE PER LINE FOR tat. Ibl. AND (c) Interval between inset and death
<br />PART U fie,''`^ /��dJ /C /J I '
<br />I
<br />al
<br />DUE TO, OR AS A CONSEQUENCE OF I Interval between onset and death
<br />I
<br />I
<br />(b)
<br />DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and death
<br />I
<br />I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related P
<br />ART 111 IF FEMALE WAS THERE A
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />II
<br />(Ages
<br />10 -54) Yes No
<br />Yes No X
<br />Yes No X
<br />26a.
<br />26b. DATE OF INJURY
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW IN, JRY OCCURRED
<br />❑ Accident ❑ Undetermined
<br />M
<br />❑ Suicide ❑ Pending
<br />26e. INJURY AT WORK
<br />EOa
<br />ddng UUR -Al hpm , )a rm. street. factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />El Homicide Investigation
<br />Yes ❑ No ❑
<br />Specal'
<br />27a. DATE OF DEATH (Mo.. Day. Yr.)
<br />28a DATE SIGNED (MO.. Day. Yr)
<br />28b. TIME OF DEATH
<br />October 6, 2004
<br />Y
<br />M
<br />$ 75
<br />27b. DATE SIGNE /MO.. y.�Y/r�./
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (MO.. Day, Yc)
<br />28d. PRONOUNCED DEAD (Fbud
<br />a J
<br />p
<br />O V
<br />7 :19 P. M
<br />a <�
<br />¢_�
<br />°
<br />M
<br />27d. To the f my owledge. death occurrod time- date and place due to the
<br />2Be. On the basis of examination and,a investigation, in my opinion death occurred at
<br />cause(s) ted.
<br />v
<br />th e time, date and place and due to the cause(sl stated.
<br />(Signature and Title) P.
<br />(Signature and Title)
<br />29, DID TOBACCO USE CONTRIBUTE TO THE TH? / }
<br />-a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 131
<br />WAS CONSENT GRANTED?
<br />❑
<br />❑ YES NO El UNKNOWN
<br />❑ YES p(I N0
<br />YES .. NO
<br />31 _ NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Gordon Hrnicek M.D. 729.4N. Custer Ave. Grand Island NE 68803
<br />32a. REGISTRAR
<br />32b. DATE FILEDD BY REGISTRAR (Mo.. Day. Yr.)
<br />0�Y 9 l 8 E-O04
<br />V ,
<br />
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