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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE DEPARTMENT OF HEALTH,
<br />IT CERTIFIES THE BELOW TORE A TRUE COPY OF AN ORIGINAL RECORD OfI FILE YIRTH THE STATE
<br />DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY FOR
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE _ _
<br />200315358 - ETA _ Y S. COOPER
<br />JUL 12 1985
<br />ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA NEBRASKA DEPARTMENT OF it TH
<br />STATE OF NEBRASKA — DEPARTMENT OF HEALTH =_
<br />Q 8 Q BUREAU OF VITAL STATISTICS 200406358
<br />O CERTIFICATE OF DEATH
<br />1 DECEDENT NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3. DATE OF DEATH tMonN Da. Year
<br />Carl Arthur Martin Hoffer
<br />Male
<br />June 29, 1995
<br />4 C11 Y AND STATE OF BIRTH dt not rn US A name country
<br />Sa AGE - Last BlrtI
<br />UNDER t YEAR
<br />UNDER I DAY
<br />6 DATE OF BIRTH :Monts Dal Year
<br />Reliance, South Dakota
<br />IVrs �
<br />78
<br />50 "'OS DAYS
<br />Sc HOURS MINIS
<br />March 20, 1917
<br />7 SOCIAL SECURTIY NUMBER
<br />9, PLACE OF DEATH
<br />506 -12 -7770
<br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing HOme
<br />® ER Outpatient ❑ Resdence
<br />Bo FACILITY - Name !e not give street and number/
<br />t Mary Lanning Memorial Hospital
<br />❑ DOA ❑ °ne' $°e'" __-
<br />8, C11 T3WN OR LOCATION OF DEATH I Bo INSIDE CITY LIMITS i Fo COUNTY OF DEATH
<br />Hastings Yea ® No ❑'' Adams
<br />9a RESIDENCE STATE 19b COUNTY
<br />9c CITY TOWN OR LOCATION
<br />_
<br />90 STREET AND NUMBER i,, udlrlg Zlp Lode, NSIDE CITY LIMITS
<br />Nebraska 1 Hall
<br />Grand Island
<br />228 N. Ruby,_ 68803 Yes No ❑
<br />IC: PACE eg Whne 31ac.. American Indian ,. t1 ANCESTRY 'eg Italian Mexican. German. etcl 12 ® MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE Ir w,re �ve ma u,- game
<br />e,, S:•.'c:N ISpeC:fyl NEJFR
<br />White American DIVORCED
<br />Pauline P. Reimers
<br />MARDI
<br />Ida 'USUAL OCCUPATION Give crndot —A done during most
<br />t 4b KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION ,SDK N only nlgnest graoe completed
<br />Elementary or Secondary 10 121 Coiled, '- 4 �I �-
<br />8
<br />of wor.,ng 'rte. even d refried,
<br />Owner /Operator
<br />Carpet Service
<br />.F FATHER NAME FIRST MIDDLE LAST
<br />MOTHER FIRST MIODLF MAIDEN So PNAME
<br />Jacob Hoffer
<br />Eva Schaffer
<br />Ill WAS DECEASED EVER IN US ARMED FORCES' 12/ 1942
<br />19a INFORMANT NAME
<br />III yes give war add dates of rvo
<br />(Yes ne o, Unk se
<br />I
<br />Yes World War II 11/13/19451
<br />Pauline Hoffer
<br />! 19b INFORMANT MAILING ADDRESS (STREET OR R D NO CITY OR TOWN STATE. ZIPI
<br />228 N. Ruby Ave. GratZd Island, Nebraska 68803
<br />'.2 M L R -SIGNATl NS
<br />#1194
<br />21a METHODOF DISPOSITION
<br />21b DATE 1 21c
<br />CEMETERY OR CREMATORY NAME
<br />,2:v� , `'
<br />OBunal ❑Removal
<br />0� 7/03/1995
<br />Grand Island City Cemeter
<br />f 22a FUNERAL NOME - NAME
<br />21d CEMETERY OR CREMATORY LOCATION CITY )R TOWN STATE
<br />Apfel - Butler- Geddes Funeral Hone[]
<br />re akin ❑Dona "pr
<br />v m
<br />I Grand Island, Nebraska
<br />j22p `JNtMAL I1VMt AUUHtJJ IJ In��, vn nrv.v i.ivr`,v..i.. ter..: �.c 1
<br />11123 West Second Grand Island Nebras
<br />23 IMMEDIIAT/Ef,`� U/S1 (ENTER ONLY ONE
<br />PART. / //
<br />68801 -5899
<br />iR LINE FOR al '.b, AND loll
<br />Interval between onset and r
<br />DUE TO. OR AS A CONSEQUENCE OF
<br />Interval between onset anc dean
<br />Ib,
<br />OUE 10. OR AS A CONSEQUENCE GF
<br />icl
<br />Imerval oetween onset ann deal,
<br />OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but rot related
<br />PART III IF FEMALE WAS THERE A 24 AUTOPSY
<br />25 WAS CASE REFERRED TO MEDICAL
<br />PART
<br />PREGNANCY IN THE PAST 3 MONTHS'
<br />R OR CORONER.,
<br />(Ages 10 -541 Yes No Ves No
<br />Yes No
<br />26,
<br />26b DATE OF INJURY IMO Day. Yr./
<br />I
<br />26c HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />F—I
<br />Ire -I, Acc�cent Unoeterm,ned
<br />M
<br />�,1 I 1 So— �� Pendlnq 2fie INJURY AT WORK 26f PLACE OF JURY - Aj home/ farm.
<br />streel factory 26g LOCATION STREET OR R F D NO CITY OR TOWN STATE
<br />I !—I office building elc /$
<br />! H.—cle Inves"9aoon Yes F—] No R
<br />L—
<br />2. )ATE OF DEATH Mo Dat Yr l
<br />28a DATE SIGNED IMO Dav Y, : 128t; TIME OF DEATH
<br />June 29, 1995
<br />M
<br />_ 271, DAT F DEATH
<br />4 i 28, PRONOUNCED DEAD MO Day, Yr 28d PRONOUNCED DEAD ;Hour
<br />E'
<br />i'
<br />M
<br />r
<br />! M
<br />g o 0
<br />- d 1270 T,, the pest my tlnpwled eam oec ,eo a Ume. a na DI M due I
<br />cause!sl staled
<br />2Be On the bases OI examination and or mges"gaoo n . In my opinion deatr dccured a1
<br />- the Ilene. date and place am due to the causelsl stated
<br />S�dnatwe and Talel ►
<br />'S nature and Tltlel ►
<br />29 DID TOBACCO USE CONTRIBUTE TO DEATH'
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' 30 b WAS CONSENT GRANTED'
<br />YES ❑ UNKNOWN
<br />YES ❑ NO YES y� NC
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEY,
<br />Type or Print
<br />Dr. John A. Beck, M.D. 715 N. St. Joseph Hastings, Nebraska 68901
<br />32a R1, 61'',1RAH
<br />L_ - --
<br />JUL 101995
<br />7
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