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C� 1
<br />2. SEX
<br />3. DATE OF DEATH Jklorith Day. year)
<br />Albert NMN Mierau
<br />=
<br />October 1, 1997
<br />4. CITY AND STATE OF BIRTH p/not it U.S.A. Mme courreyl
<br />So. AGE - Last BirMlday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH M4orah, Day. Year)
<br />York County, Nebraska
<br />(Y's) SD.
<br />65
<br />May 14, 1932
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<br />7. SOCIAL SECURTIY NUMBER
<br />Be. PLACE OF DEATH
<br />506 -36 -2335
<br />HOSPITAL. ® Inpatient OTHER: ❑ Nursing Home
<br />❑ ER Outpaearre ❑ Residence
<br />Bh FACILITY - Name (era naeR,aorr. give ernes/ and mimbed
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other rspecdy/
<br />8c. CITY, TOWN OR LOCATION OF DEATH
<br />84. INSIDE CITY LIMITS
<br />c
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<br />Hall
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<br />9b. COUNTY
<br />9c. CRY. TOWN OR LOCATION
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<br />9e. INSIDE CITY LIMITS
<br />n
<br />Hall
<br />Z
<br />1816 W. Anna 68801
<br />Yes IN No ❑
<br />11. ANCESTRY le.g.. Malian. Mexican. German, etc)
<br />C, (P
<br />13. NAME OF SPOUSE (d wile, give maiden name)
<br />W- 1(Spec4yl White
<br />ISpecdyl German
<br />I
<br />Fn
<br />>
<br />N�
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade comPI"M
<br />>11
<br />_
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<br />n
<br />Frank J. Mierau
<br />Anna NMN Martens
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />C
<br />O
<br />Delores Mierau
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />816 W. Anna, Grand Island, Ne. 68801
<br />8 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21
<br />c. CEMETERY OR CREMATORY . NAME
<br />ra;=,URE
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<br />C:)
<br />O -n
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<br />22a. FUNERAL HOME - NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston- Sondermann F.H.
<br />❑Oonatan
<br />Gibbon, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP(
<br />601 N. Webb Road, Grand Island, Ne. 68803 -4050
<br />23. IMMEDIAT CAU/S�E r IENTER ONLY ONE CAUSE PER LINE FOR la)- Ibl, AND Ich I Interval between onset and death
<br />PP,
<br />AN
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<br />�V ' v Tt gi 0 2 W1 i�- Myo C fi�J rA L 1rsFi'� 2c -i w� 3 �it,�vw,
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<br />DUE TO. OR AS A CONSEQUENCE OF. I Interval between onsel and death
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<br />IN
<br />DUE TO. OR AS A CONSEQUENCE OF Interval between meal and deem
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<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A 24.
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
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<br />D C33
<br />O
<br />,N�.
<br />10 -541 Yes No
<br />Yes No
<br />� Yes No
<br />2W.
<br />26b. DATE OF INJURY (MO.. Day. Yr.J
<br />26c. HOUR OF INJURY
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<br />I] Suicide Pending
<br />26e. INJURY AT WORK
<br />261. PLACE OF INJBUkRY ,A"hop. farm, street. factory
<br />269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />I
<br />Hornidide Invespgatim
<br />Y051:1 � ❑
<br />2
<br />27a. DATE OF DEAT (Ato.. Day.
<br />26a. DATE SIGNED (W... Day. Yr)
<br />28b TIME OF DEATH
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<br />�Yr..)
<br />D i)'17 /
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<br />Z7b. DATE SIGNEO rw Day Yi)
<br />27c. TIME OF DEATH
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<br />28d. PRONOUNCED DEAD (Haul
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<br />289. On the basis of examination and/or investigation, in my opinion death occurred at
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<br />WHEN THIS COPY CARRES TIE RAISED SEAL OF THE NEBRASKA HEALTH AND HU1WA _:_ .
<br />SYSTEK !! CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGNVAL RECOIAk*VXEJ1_ = __
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM VITAL STA 71SIMS 30
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS _
<br />DATE OF ISSUANCE 200309581
<br />OCT 7 1997 ASSISTANTLATE Rf
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN =
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH -_-
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />1. DWEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH Jklorith Day. year)
<br />Albert NMN Mierau
<br />Male
<br />October 1, 1997
<br />4. CITY AND STATE OF BIRTH p/not it U.S.A. Mme courreyl
<br />So. AGE - Last BirMlday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH M4orah, Day. Year)
<br />York County, Nebraska
<br />(Y's) SD.
<br />65
<br />May 14, 1932
<br />MOS. DAYS
<br />1
<br />Sc. MOURS � MINS.
<br />7. SOCIAL SECURTIY NUMBER
<br />Be. PLACE OF DEATH
<br />506 -36 -2335
<br />HOSPITAL. ® Inpatient OTHER: ❑ Nursing Home
<br />❑ ER Outpaearre ❑ Residence
<br />Bh FACILITY - Name (era naeR,aorr. give ernes/ and mimbed
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other rspecdy/
<br />8c. CITY, TOWN OR LOCATION OF DEATH
<br />84. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yea IN No ❑
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CRY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER rerc4rtlVZp Code)
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1816 W. Anna 68801
<br />Yes IN No ❑
<br />10. RACE - le.g.. While. Black. American Indian.
<br />11. ANCESTRY le.g.. Malian. Mexican. German, etc)
<br />t 2. MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (d wile, give maiden name)
<br />W- 1(Spec4yl White
<br />ISpecdyl German
<br />I
<br />NEVER DIVORCED
<br />Delores Stevens
<br />1
<br />t4a. USUAL OCCUPATION /Give kindo( wDA dare Awing most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade comPI"M
<br />IrA9, a Araere/
<br />Se r mp oye Auto Mechanic
<br />Auto Repair
<br />lE�t tra=e 10 -121 cettege 1, -4a5 -I
<br />16. FATHER -NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Frank J. Mierau
<br />Anna NMN Martens
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yes. M. or unk.l In yes. give war and dates of services)
<br />No - - - - --
<br />I
<br />Delores Mierau
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />816 W. Anna, Grand Island, Ne. 68801
<br />8 LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21
<br />c. CEMETERY OR CREMATORY . NAME
<br />ra;=,URE
<br />/Q. oQ(,t ��43
<br />El Burial F] Removal
<br />Oct. 3, 1997
<br />Central Ne. Cremation Sery
<br />22a. FUNERAL HOME - NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston- Sondermann F.H.
<br />❑Oonatan
<br />Gibbon, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP(
<br />601 N. Webb Road, Grand Island, Ne. 68803 -4050
<br />23. IMMEDIAT CAU/S�E r IENTER ONLY ONE CAUSE PER LINE FOR la)- Ibl, AND Ich I Interval between onset and death
<br />PP,
<br />AN
<br />,,{r^
<br />�V ' v Tt gi 0 2 W1 i�- Myo C fi�J rA L 1rsFi'� 2c -i w� 3 �it,�vw,
<br />DUE TO. OR AS A CONSEQUENCE OF. I Interval between onsel and death
<br />■ I
<br />I
<br />IN
<br />DUE TO. OR AS A CONSEQUENCE OF Interval between meal and deem
<br />I
<br />I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A 24.
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS? �/
<br />"1
<br />EXAMINER OR CORONER?
<br />M
<br />)Ages
<br />10 -541 Yes No
<br />Yes No
<br />� Yes No
<br />2W.
<br />26b. DATE OF INJURY (MO.. Day. Yr.J
<br />26c. HOUR OF INJURY
<br />28d. DESCRIBE MOW INJURY OCCURRED
<br />Accident � Undetermined
<br />M
<br />I] Suicide Pending
<br />26e. INJURY AT WORK
<br />261. PLACE OF INJBUkRY ,A"hop. farm, street. factory
<br />269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />I
<br />Hornidide Invespgatim
<br />Y051:1 � ❑
<br />dfi otwdsrg,
<br />27a. DATE OF DEAT (Ato.. Day.
<br />26a. DATE SIGNED (W... Day. Yr)
<br />28b TIME OF DEATH
<br />i
<br />�Yr..)
<br />D i)'17 /
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<br />Z7b. DATE SIGNEO rw Day Yi)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (Aild. Dry. Yr.)
<br />28d. PRONOUNCED DEAD (Haul
<br />it �© I I
<br />S• 1/ r 11- 1 M
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<br />27d. To the best of my k . Oeatl1 occurred at the time, date and place and due 10 the
<br />289. On the basis of examination and/or investigation, in my opinion death occurred at
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<br />N
<br />�yuselsl stated. C___
<br />. a
<br />the lime. data and place and due to the cause(s) staled.
<br />__
<br />S re and T111a
<br />re and Tide
<br />29, DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />X YES ❑ NO ❑ UNKNOWN
<br />A,- ❑ YES NO
<br />❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHVSICUW, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print/
<br />�irD.3
<br />A k 19 094 k n-f- . f k esi-T �: 3� 3J jam . 2 ao, C-S "E
<br />-k- r I
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR µb., Day. W..)
<br />u
<br />Lot Eight (8), Block Two (2), Bartling's Subdivision to the City of Grand Island, Hall County, Nebraska.
<br />
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