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WHEN THIS.COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE _DEP�+IZ ta i HEALTH, IT CERTIFIES THE BELOW TO SEA TRUE COPY OF AN ORIGINAL RECOIiQ FILE -T1 STATE DEPARTMENT OF HEALTH, BUREAU OF V ?AL STATISTICS, WHICH & €1fflr AI_ YFOR V ?AL RECORDS. _ DATE OF ISSUANCE - S. JUL 31 1995 RE`DER A33`ISTAA? E TRAR LINCOLN, NEBRASKA NEBRASICQk QEPARlA7k-- bETIE4L7H STATE OF NEBRASKA — DEPARTMENT OP "LTif BUREAU OF VITAL STATISTICS 200202108 CERTIFICATE OF DEATH 1 DECEDENT - NAME FIRST MIDDLE LAST 2 SEX 3 DATE OF DEATH ;Moan Dav "arI Darrel Herman Alberts Male July 14, 1995 4 CITY AND STATE OF BIRTH lent in US A namecountryl 5a AGE - Last Blmlday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH ,Month Dav ✓earl Wood River Nebraska IYrs 84 April 3, 1911 5b MOS DAYS 5C. HOURS MINS 7 SOCIAL SECURTIY NUMBER Ba PLACE OF DEATH 508-46-7132 HOSPITAL Inpatient OTHER ❑ Nursing Home - -- — —_ ❑ ER IDutilletienl ❑ Residence 8b FACILITY - Name In not msht~ give street and numDBlf St. Francis Medical Center ❑ DOA ❑ Otne..Soe „IV -- 8c CITY TOWN OR LOCATION OF DEATH Bid INSIDE CITY LIMITS I Be COUNTY OF DEATH Grand Island YesU No El! Hall 9a RESIDENCE - STATE . 9b COUNTY 9c CITY. TOWN OR LOCATION 9d STREET AND NUMBER I1,—dlhgzPCodel 9e INS1}_ CITY LIMITS Nebraska !Hall Wood River 116625 W. Lepin Rd. 68883 Yes ❑ No 10 RACE - is 9., While Black American Indian 11. ANCESTRY leg Italian. Mexican, German. etcl 12 n MARRIED ❑ WIDOWED 13 NAME OF SPOUSE ill wile Orve maiden name etc) ISpecl �Jhite tSDec4yl German NEVER DIVORCED Doris Hogg MARRI 14a USUAL OCCUPATION tGrve krndol work done durvl9 most, 14b KIND OF BUSINESS INDUSTRY 15 EDUCATION :Scii only mghest grade compleledl d workng IAe. even dretrredl Farming Agriculture Elements Secondary (0 12) College ' �� 16 FATHER - NAME FIRST MIDDLE LAST MOTHER FIRST MIDDLE MAIDEN SURNAME 117 George F. Alberts Julia C. Madsen 18 WAS DECEASED EVER IN US ARMED FORCES' 19a INFORMANT NAME IYes no or unk.) III yes give war and dales of senitesl NO I Doris Alberts 19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D NO, CITY OR TOWN. STATE. ZIP) 16625 W. Lepin Rd. Wood River, NE. 68883 20 EMBALMER - SIGNATURE 8 LKENSE NO 21a METHOD OF DISPOSITION 21b. DATE 21c CEMETERY OR CREMATORY NAME . n l PBurlal ❑ Jul 17, 1995 Wood River Cemetery Removal 22. FU L FjjME - NAME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel Funeral Home ❑Gemallm 0 D0na0o, Wood River NE 22b FUNERAL HOME ADDRESS [STREET OR RIF D. NO CITY OR TOWN. STATE. ZIP) Wood River , NE 68883 -126 23, IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b). AND (c)1 Interval between orsse� ar, Ream PART /� ^{L ! / /^ /0 ��/r I /1//� o�, na 4 �s/ t, r� c, rlQivi sH„ arcc w-ce(c lal u Y _v 1L I/t, t ! ' DUE TO. OR AS A CONSE (fUENCE OF interval L Interval between one, — —li- v b) /li l /�6 ,-) DUE TO. OR AS A CONSEOUENCE OF Idlerval between D ^se ax .ean (c) OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but nOt —relatedl PART bl IF FEMALE. WAS THERE A 24 AUTOPSY 25 WAS CASE REFERRE_ "_ MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS' ” EXAMINER OR COR-NE'' (Ages 10 -541 Yes No Ves Nc Yes N; K 26a 26b DATE OF INJURY rMo Day. Yr.) 26c HOUR OF INJURY DESCRIBE HOW INJURY OCCURRED Accident Undelerm,hed 126d. M Suicide Pending 26e INJURY AT WORK farm. sveel. factory 26g. LOCATION STREET OR R F C NO CITY OR TOWI: S "=TF PLACE E OF IN e1RY 1261 rS�p� Homicide Investlgatlon Yes ❑ NO ❑ I 27a DATE OF DEATH (MC Dgr ! 28a DATE SIGNED (MI Dar yr 28o TIME OF DEATH /.✓,) �� I27b i N DATE SIGNED IMo as 27c TIME OF DEATH 4 > ! > 28: PRONOUNCED DEACC Mo Day ✓' .j 2Bd PRONOUNCE DEAD Q P 3°I °N'° ¢ P- goo27c M S ice Ih b451 01 my kno edge leatn a ed at e t date and place aritl tlue to the < I , 28e On the bans OI exdm�na; ^^ and 0� InveS' .allph . in my Op�niUr death (N'C Ur'C:, a' causels, slatetl. ��/ • ^/ - the time. date and place a,c due to the :a.selsl staled � �S:goature and T11el), WV✓ SI nature and Tlnel ► 29 DID TOBACCO USE CONTRIBUTE T ATHI 30 a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED" 30 o WAS _ONSENT 3RANTED-r - ❑ YES NC ❑ UNKNOWN ❑ YES NO ❑ YES J1 NAMEANUAUUHt SJU'LtHlwitn hull, —1',- Gar L. Sett'e M.D., 2116 W faidle , Grand Island, Nebraska 68803 _ 32a REGISTRAR 32, DATE FILED BN REGISTRAR rMO Dav ✓� I �!._ - - - -- -- - - - - - -- - J U L 2 71995 I