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rA�i44 <br />N rMt C0"CAjnw,7 f RAIit3 1L 0i THE NEBRASKA Mull, <br />SYtTM lTCER"S iFNAMOW TO,#E A TRUE COPTOF ME <br />8 : THE NE AASKA HEALMAND MU~ SERW.ES SY$TW MAC.9 <br />;, <br />THE LEOM. DEPOSITORYFOR W/'TAL JWCORM <br />DATE OF' .._ ,, -.. <br />MAY 3 2002 l -� <br />UNCOIA NUMSKA <br />A ` ` • ` STA1E OF NEBRASKA - D&ARTbH'iW OF HEALTH ANFiEi[�Atts$ F 1 <br />MAL S1AT1SiT�9 = <br />CERTIFICATE bF DEATfi # y <br />1, <br />LZ <br />s.? <br />I. DECEDENT -NAME FIRST 'MIDDLE - LAST - <br />3. SEX ;'° ,� <br />01ITE OF DEATH /Moan. Day. Yea" <br />Arthur Henry Stange 7- <br />fa-, <br />Male ' <br />Aril 23, 2002 <br />4. CITY AND STATE OF BIRTH' M MW it USA. narha country) <br />5a. AGE - laat BklMay, <br />UNDER t YEAR <br />UNDER /DAY <br />6. DATE OF BIRTH— Mon1f; Day ear) „ <br />5b. MOS DAYS <br />Sc:HOURS MINS <br />Bremen, Germany <br />(Yrs.) 88 <br />October 10, 1913 <br />7. SOCIAL SECURTIY NUMBER <br />7... <br />8e, PLACE OF DEATH <br />P: ❑_ OTHER ® Nay Hama` <br />506 -09 -5934 <br />- - - <br />- ❑ ER Outpatient ❑ Residence <br />Bb. FACILITY Name . /d nor rota mon, yNpsMreeM and number) - <br />-- <br />:',- �i f �lC.i�W4 r'IIr °� "��$.. iiV 'J �.:.. -. '� ` .. - <br />4 : ` a A . -.� DLL it a r , -❑ Orlef /Sti4CI�YM <br />'Sc CITV. OR LOCATION OF DEATH <br />0& INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island <br />Y« Xn Ne ❑ <br />Hall <br />9a. RESIDENCE -STATE <br />91) . COUNTY <br />. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER Jftkoft Z*) Coale) <br />9e, INSIDE CITY LIMITS <br />Nebraska <br />Hall 7 <br />Grand Island <br />418 N. Webb Road, 68803 <br />Ye! ®Ne ❑ <br />10. RACE • (e.g., While. Black. American k4an <br />11. ANCESTRY te.g.. Ileum Mewan. German. tact <br />12. MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE . /e wde. give maiden rMmal <br />MI IS 014 White <br />(soma" German <br />I <br />DIVORCED <br />MARRIED I <br />Blanche Evelyn Adel <br />74a.• USUALOCCUPATION /Gweimdo/w&* dar AIM MOM <br />14b. KIND OF BUSINESS INDUSTRY - - <br />. EDUCATION <br />(Speady0ny ll"Id grade cdmpleladl ' <br />ElememaY or SaeaMary (0 121 Co" 11 -4 a 5•) <br />r <br />of wo*Nv /bFa, ~ I niontedi - <br />.. ._... 4 xmwr+ k - <br />Private Contractor <br />Construction <br />12th Grade <br />16. FATHER -NAME FIRST. MIDDLE LAST <br />77 MOTHER FIRST MIDDLE... '.MAIDEN SURNAME <br />Arthur Stange <br />Bertha .Metzdorf <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? - <br />- <br />- <br />19a.. INFORMANT - NAME{, <br />(Yes.no.orumt.) Id ys& gift war and dam otwvIcael. <br />Yes II 1- 7- .1942/3 -20 -1946 <br />} A <br />�3 =.it e. -. A y . 1' $i.' 2$ <br />Blanche Stange <br />g <br />19b. INFORMANT MAILING ADDRESS . (STREET OR "FIF U NO.. CITY OR TOWN. S 1 A I t. [I VI <br />418 N. Webb Road, Grand Island, Nebraska 68803 <br />20. LMER - SIGNATURE 6 LICENSE NO 21 a. METHOD OF DISPOSITION 21b. DATE <br />�. �0/ ® Banal ❑ Renaval Apr. 2 <br />22a. FUNERAL HOME - NAME 21d CEMETER' <br />Livingston- Sondermann F.H. ❑clwnon 1:1 Donato, Gr <br />22b. FUNERAL HOME ADDRESS {STREET OR R.F.O. NO.. CITY OR TOWN STATE, PIP( <br />r� <br />MR� <br />w� <br />44s <br />a <br />21C. CEMETERY OR CREMATORY NAME , <br />v� <br />2002 Westlawn.Memorial Parke <br />EMATORY LOCATION CITY OR TOWN STATE �• ".,: <br />Island, Nebraska¢ <br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la). (b). AND (c)l I Interval balmmeen ones and death <br />PART I <br />I, Cardio Respiratory Arrest a few hours.. <br />fb) Aspiration Pneumonia ;one month <br />DUE TO. OR AS A CONSEOVENCE OF: I Interval bet~ onset ant death ...a <br />I <br />,c, Congestive Heart Failure a few years '; <br />PART OTHER SIGNIFICANT CONDITIONS - Conditions ConItY"ng to the death but not related PREGNANCY W <br />WALE. PASfi 3 MONTHS? 124 A <br />AUTOPSY 2 <br />25. XA �ICASE REFERRED TO MEDICAL <br />II - <br />Deh dration /Anorexia ( <br />(Ages 10.541 Yea NO 171 Y <br />Yes El No Y <br />Yes No 9 <br />26a. 2 <br />26b. DATE OF 04JURY /Asa. Day. Yr.) 2 <br />26c. HOUR OF INJURY 2 <br />26d. DESCRIBE. IOW INJURY OCCURRED gq g <br />Suicide ❑ Pending 2 <br />26w INJURY AT WORK 2 <br />261, PLACCE OF 1NJ RY Mc tam. street factory 2 <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE - <br />