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<br />
<br />WHEN TH/S'CQPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMAN SERWCES
<br />SY,S71:M,ITCERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINA~E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA~tll:l~~ IS
<br />THE LEGAL DEPOSITORY)=OR VITAL RECORD&. ~. "-. ~.~ #~:{i::.i.ij~?trii:t~
<br />DA TE OF ISSUANCE . '.=- --'. tJ,.~fif'
<br />'jUt 2 0 1999 20051045 2 ~;Z'A~';~~~~=:
<br />LINCOLN, NEBRASKA HEAL TH ANlttinillAlI. $EImc:E$::SfttiM
<br />STAlE OF NEBRASKA. DEPARTMENT OF HEALlli AND HllMki~ER~-ANn:iUPPORT
<br />VITALSTATISTICS.c",,- ...... 3"'
<br />CERTIFICATE OF DEATH<:. _...:_.~;.=--
<br />
<br />1. DECEDENT NAME
<br />
<br />
<br />May 13, 1930
<br />
<br />LAST
<br />
<br />2. SEx
<br />
<br />DATE OF DEATH {Month. Day. Y""r}
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />Donald
<br />
<br />Male
<br />
<br />July 10, 1999
<br />6. DATE OF BIRTH r_. Day. Y..,)
<br />
<br />F.
<br />
<br />Paustian
<br />
<br />4. CIlY ANO STATE OF BIRTH Iii not in U.S.A.. n,mll COlJ{1ttyj
<br />
<br />~a. AGE - Lut BirtMay
<br />IY"I 69
<br />
<br />uNDER' YEAR
<br />5~ MOS. DAYS
<br />
<br />Grand Island. Nebraska
<br />7 SOCIAL SECURTIY NUMaE~
<br />
<br />8.. PLACE OF DEATH
<br />HOSPITAL. 0 Inpatient
<br />
<br />o ER OUlpati81"1t
<br />
<br />o DOA
<br />
<br />OlHEi=I. D NurSIng Home
<br />o R'.'dOne. Lot 1174. TrailE
<br />~ Othor,Sp<<'fy,Sherman ReserviOl
<br />
<br />508-28-7705
<br />
<br />8b, FACILITY. Name
<br />
<br />(n not Institution, giVfl strver and nI,JmbIIr)
<br />
<br />Lot #74 Sherman Reservior
<br />
<br />
<br />Rohweder
<br />
<br />8<. CITY. TOWN OR LOCATION OF DEATH
<br />
<br />I Luup C..i.Ly
<br />9&, RESIDENCE. STATE
<br />
<br />Nebraska
<br />
<br />
<br />Ilncl<xling Z", C_I 90. INSIDE CITY LIMITS
<br />
<br />68803
<br />
<br />Yes [Xl No D
<br />
<br />Hall
<br />
<br />13th
<br />
<br />10, RACE - (e.g.. Wn~le. Black" American Il"Idian
<br />etc,l rSpeclfyl
<br />
<br />11. ANCESTRY (e.g. ttalian. Mexican. German, etl;l
<br />ISpec>1y1
<br />
<br />Arlene Nuss
<br />
<br />13 NAME OF SPOUSE 1# wile. gi"" fIl4/(JO" ""mo)
<br />
<br />White
<br />
<br />German
<br />
<br />14a. USUAL OCCUPA lION (GlVtJ kind of work don8 during most
<br />of working life. even if retired;
<br />
<br />Engineer
<br />
<br />18 FATHER. NAME FIRST MIDDLE
<br />
<br />.5. EDUCATION (Spoe,1y only n'911Oatg<ad. eomplolo(ll
<br />Et'2'ttO'~r~J~O"21 College 11.40'5'1
<br />
<br />MIDDLE MAIDEN SURNAME
<br />
<br />V.P. Railroad
<br />LAST
<br />
<br />John
<br />
<br />a
<br />
<br />NMN
<br />
<br />NMN
<br />
<br />18. WAS DECEASED EVER IN US ARMED FORCES?
<br />(Yes, 110 (.r '.mlo I I (II yes, give ntH and oale~'~ servicesl
<br />Yes ;1-17-1949-1-'-16-1950 Arlene Paustian - Hife
<br />190. 'NFORMANT MAILING ADDRESS ISTREET OR RFD NO.. CITY OR TOWN STATE. ZIPI
<br />
<br />
<br />Island. Nebraska 68803
<br />
<br />
<br />218. ME THOD OF DISPOSITION
<br />
<br />21 e. CEMETERY OR CREMA TORY NAME
<br />
<br />S"t.J,b
<br />
<br />.KJ aurial
<br />
<br />Grand Island Cit
<br />CITY OR TOWN
<br />
<br />13,
<br />
<br />1999
<br />
<br />Cemetery
<br />STATE
<br />
<br />FuNERAL jE NAMe
<br />
<br />Livi~ston-Sondermann F.H.
<br />,uNERAL HOME ADDRES" (STREET OR RFD. NO.. CITY OR TOWN. STATE. ZIPI
<br />
<br />o Cremation 0 Oof'alluf'
<br />
<br />Island
<br />
<br />Nebraska
<br />
<br />I 22b
<br />
<br />i 601N. Webb Road,
<br />23 IMMEDIATe CAUSE
<br />PART
<br />
<br />Grand Island. Nebraska 68803-4050
<br />(ENTER ONLY ONo CAUSE PER LINE FOR lal.lbl. AND (ell
<br />
<br />Interval between onset and dealt1
<br />
<br />
<br />~ minutes
<br />
<br />Cardiac
<br />
<br />Arrest
<br />
<br />lal
<br />DUE TO. OR AS A CONSEOUENCE OF
<br />
<br />Intervill between onset ana death
<br />
<br />Ibl
<br />'-~"'''''[;Uc TO. on AS A CONswueNCE OF
<br />
<br />r interval~$R6I!1 a;1;:: :::g.;:;.'"
<br />I
<br />I
<br />I
<br />25. WAS CASE REfERRED TO MEDICAL
<br />EXAMINER OR CORONEA'
<br />....f~ Yes X
<br />
<br />lei
<br />OHiE.R' SIGNIFICANT CONDITIONS - Conditions contributing 10 the death but not relared
<br />PART
<br />II
<br />
<br />26a
<br />
<br />
<br />26b, OATI:: OF INJURY (Mo.,Oay. Yr.) 26c:. HOUR OF INJURY
<br />
<br />o AccIdent 0 Un(1elermlned
<br />D SUlcloe 0 Pendmq 26e. INJuRY AT WORK
<br />o HOr"uCldf> h'lV~stlgabOr1 Yes 0 No 0
<br />) -~---"'-'-'
<br />, Z 1 '?la DArE OF DEATH (Mo.Oay, '1r.}
<br />
<br />f;~
<br />1 ~ >- <7b OATE" SIGNED (Mo. Day, Yr.) :27c, TIME OF DEATH
<br />
<br />rIg
<br />~ 210, To 1M best 01 my knowledge, dea1h occurred at the lime. da1e and place and due to Ihe
<br />cause/sf slated.
<br />
<br />STREIOT OR R.F.O. NO.
<br />
<br />CITy OR TOWN STATE
<br />
<br />26g LOCATION
<br />
<br />2Ba, DArE: SIGNED (Mo,. Da't. '1r.!
<br />
<br />28b TIME OF DEATH
<br />;:{12:01
<br />
<br />M
<br />
<br />XJul 14, 1999
<br />
<br />28e. PRONOuNCED DEAD rMo. O.y., Yr,}
<br />
<br />~~ ~
<br />QiiZ
<br />hL
<br />p~g
<br />~h
<br />8 ~
<br />
<br />280. PRONOUNCED DEAD (Houri
<br />
<br />X6:10
<br />
<br />
<br />
<br />M
<br />
<br />M
<br />
<br />DYES
<br />
<br />[iJ NO
<br />
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY, ITy.p<l or p,",ti
<br />~erman County Sheriff & Deputy Coroner, ~ O.
<br />32.. REGISTRAR
<br />
<br />
<br />Kugler PO Box 127 Loup Cit
<br />32b. DATE FILED BY JUCA!V1999
<br />
<br />NE.
<br />
<br />688:
<br />
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