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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTME�+t�F�k'F,�I'
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOS -TORe''.,
<br />VITAL RECORDS. '
<br />DATE OF ISSUANCE
<br />e�
<br />NOV Z 110 �;R
<br />p STANLEY S. COC DIRECT 1'
<br />LINCOLN, NEBRASKA 20030510 9 BUREAU OF VITAL 3TFI�S":
<br />i
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH (Month. Day. Year)
<br />Elmer NMI Krueger
<br />IMale
<br />Sept.29, 1989
<br />4. CITY AND STATE OF BIRTH (d rat in U.S.A., name country)
<br />5a. AGE - Last Birthday
<br />Donation c t. 4, 1989
<br />Burial
<br />6, DATE OF BIRTH (Month. Day. Year)
<br />5b. MOS. DAYS
<br />. HOURS' MINS.
<br />Hall County, Nebraska
<br />(Vra1
<br />// I 6
<br />July 1 0 , 1913
<br />J 1
<br />7. SOCIAL SECURITY NUMBER
<br />fie. PUCE )F DEATH ,y
<br />HOSPITAL: [XInpatient 0 EWOutpabae ❑ DOA
<br />507 -34 -6961
<br />OTHER: 0Nursing Home 0Residence 0 Other (SPeciy)
<br />8b. FACILITY -Name (d not institution, give sheet and number)
<br />Bc. CITY, TOWN OR LOCATION OF DEATH
<br />Sd. INSIDE CITY LIMITS
<br />fie. COUNTY OF DEATH
<br />Good Samaritan Hospital
<br />Kearney
<br />(sp�iy sa0 Nd)
<br />l
<br />Buffalo
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />STREET AND NUMBBER (Including Zip Code)
<br />9e. INSIDE CITY LIMITS
<br />' Nebraska
<br />Hall
<br />Grand Island
<br />Rt. 2, Box 72
<br />/specify Yes or Nol
<br />1 No
<br />10. RACE - (e.g., White, Black, American Indian,
<br />11. ANCESTRY (e.g.,IWian, Mexican, German, etc.)
<br />12. MARRIED.NEVER MARRIED,
<br />t 3. NAME OF SPOUSE (d wile, give maiden name)
<br />etc.) (Specify)
<br />White
<br />(spedly)
<br />American °�
<br />I
<br />WIDOWED. DIVORCED (Specify)
<br />Married
<br />Irene Miller
<br />14a. USUAL OCCUPATION (Give kind of work done during most
<br />of working /do. even d reared)
<br />114b. KIND OF BUSINESS INDUSTRY
<br />Etementary or Secondary (0.12) College (1 -4 or 5•)
<br />8
<br />Farmer
<br />Agriculture
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />17. MOTHER - MAIDEN NAME FIRST MIDDLE LAST
<br />Charles -- Krueger
<br />Meta - -- Muhs
<br />18. (WAS DECEASED EVEN IN U.S. AHARW rVH tbf mrvmm�n - nnm� • , ........... ........��., �.,.,,«..... ..... -.. •-. ...... -. -..., _...
<br />(Yea, ra, or unk.) I (11 yes, give war and dates of services) 6 8 Q 3
<br />114
<br />20a. BURIAL, Cremaaon,Removal, 20b. DATE
<br />20c. CEMETERY OR CREMATORY - NAME 20d.
<br />LOCATION CITY OR TOWN STATE
<br />Donation c t. 4, 1989
<br />Burial
<br />Westlawn Memorial Park
<br />Grand Island, Nebraska
<br />21. EMBAL - NA E IL SE NO,
<br />22, FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />2�
<br />11
<br />Apfel- Butler- Geddes 1123 W. 2nd, Grand IslandgOftE.
<br />23. 1 A CA (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (c)) Interval between onset and death
<br />PART
<br />Cur p u
<br />I
<br />esik-
<br />DUE TO, OR A CONSEQUENCE OF:
<br />Interval between onset and death
<br />IbI
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Interval between onset and death
<br />t
<br />I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions corNibutlng to death but not related
<br />PART III IF FEMALE, WAS THERE A
<br />24. AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />/specify Yes or No/
<br />EXAMINER OR CORONER'
<br />Il
<br />Yes 0 No ❑
<br />O
<br />(Specify Yes or Noll k '
<br />/V
<br />26a. ACCIDENT, SUICIDE, HOMICIDE, UNDET.,
<br />DATE OF INJURY (Ab..Day, Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />OR PENDING INVESTIGATION (specityl
<br />128b.
<br />26e. INJURY AT WORK
<br />261. PLACE OF INJURY - At home, term,
<br />street factory,
<br />28g. LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE
<br />(Specify Yes or No)
<br />office building, ale. (Specify)
<br />27a. DATE OF DEATTHH (Afa. y Yr.)
<br />26a. DATE SIGNED (MO., Day. Yr.)
<br />28b. TIME OF DEATH
<br />l 9 Q I
<br />a
<br />27b. DATE SIGNED /MM Day, Yr.)
<br />27c. TIME OF
<br />DEATH
<br />28c. PRONOUNCED DEAD (Mo., Day. Yr.)
<br />28d. PRONOUNCED DEAD (Hour)
<br />a
<br />Y 1a�s
<br />x
<br />qq_5
<br />H19
<br />8
<br />o
<br />27d. To the best of my knowladp. death occurred at the ., date and ppce and due to the
<br />28e. On the basis of examination andia investigation. in my opinion death occurred at
<br />causes) stated. 7A
<br />/
<br />$$ a
<br />the time, date and place and due to the causels) stated.
<br />kiSignature
<br />S' nature and Tills ►
<br />and Title)
<br />29a. OID TOBACCO USE CONTRIBUTE T TH DEATH?
<br />301. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30b. WAS CONSENT GRANTED?
<br />O YES INO 0 UNKNOWN
<br />0 YES NO
<br />O YES X NO
<br />31. NAME ANQ;DD Ee F (PHYSWCOONEffH W C3fR L OUNTYVe earne 68847
<br />Richard ��.W,aft al-8
<br />.
<br />847
<br />32L REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Mo., Day. Yr)
<br />U c T 1 0 1989
<br />(q 30
<br />
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