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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, ff CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WH0f IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE 200 210 P21 36 MAY 200 aIVI EY S..COOPER ASSISTANT STATE REGISTRAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERYTCES FINANCE AND SUPPORT VTTAL STATISTICS _ nn n / CERTIFICATE OF DEATH , 0 2 0 4 1 1 Cy r t DECEDENT - NAME FIRST MIDDLE LAST (III` 2 SEX 3. DATE OF DEATH rWnfn Dar Year] Eda Marie Dobberstein Female Aril 22, 2002 0. CITY AND STATE OF BIRTH Ulna in USA.. name counfryl AGE . Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Monet Day Yearl 51, MOS I DAYS Sc. HOURS MINS 26b. DATE OF INJURY (MO.. Day Y[1 26c HOUR OF INJURY I26d DESCRIBE HOW INJURY OCCURRED I 15a (Yrs I I Ord, Nebraska 85 Swcide I] Pending 26e INJURY AT WORK December 20, 1916 7. SOCIAL SECURTIY NUMBER 8a PLACE OF DEATH ❑ ❑ HOSPITAL ❑ Inpatient OTHER �Nursng Home 507-38-5374 ❑ ER Outpatient Residence Bb. FACILITY - Name (tt not msbfulion. give street and number) Lebensraum Retirement Home ❑ DOA ❑ Other(Specdo 8c CITY TOWN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS 8e COUNTY OF DEATH Grand island Y =•s ®rl. ❑ Hall 9a RESIDENCE - STATE 91, COUNTY 9c. CITY. TOWN OR LOCATION AND NUMBER (Including Zip Code) 9e INSIDE CITY LIMITS Nebraska Hall Grand Island [4dSTR_E_C_T 118 S. Ingalls St. 68803 Yes ® No ❑ 10 RACE - (eg., While. Black. American Indian. 11. ANCESTRY le g Italian. Mexican. German, etc) 12. ❑ MARRIED ❑ WIDOWED 13 NAME OF SPOUSE (ft w fe give maiden name) etc.) ISpecityl White ISpecifyl American NEVER DIVORCED MARRI 14a USUAL OCCUPATION fGwe kind of work done during most 141, KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completedl oary 10.121 College 11 4 or 5.1 tar or Se rld Eleme y 1Gth Grade of working Ue, even it refired) Secretary Grocery Wholesale 16. FATHER -NAME FIRST MIDDLE LAST MOTHER FIRST MIDDLE MAIDEN SURNAME 117 John W. Dobberstein Emilie L. Bremer 18 WAS DECEASED EVER IN U.S. ARMED FORCES? 19a INFORMANT - NAME (Yes. no or onk.) III yes. give at and dates of services) 30.b WAS CONSENT GRANTED' (� ❑ No -- - - - - -- I Joyce Sullivan 191, INFORMANT MAILING ADDRESS (STREET OR R.F.D NO. CITY OR TOWN. STATE. ZIP) P.O. B 73, Elgin, Nebraska 68636 20. E - SIGN AT RE 8 SE N � 21a METHODOF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY - NAME 191 Burial ❑Removal Apr. 25, 2002 Westlawn Memorial Park 22a FUNERAL H - NAME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Livingston- Sondermann F.H. ❑Crematron ❑Donaka Grand Island, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN, STAIE. LIP) 601 N. Webb Road, Grand Island, Nebraska 68803 -4050 23 IMMEDIATE CAUSE IENTER ONLY ONE CAUSE PER LINE FOR (a) (bl, AND (c)I Interval between onset and Beam ART I lal .v—, U' - DUE TO, OR AS A CONSEQUENCE OF Iniewal between onset and deal- I lb) DUE TO. OR AS A CONSEQUENCE OF Interval between onset and death OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS' - EXAMINER OR CORONERn (Ages 10 -54) Yes ❑ No Yes ❑ No Yes ❑ No �! 26a 26b. DATE OF INJURY (MO.. Day Y[1 26c HOUR OF INJURY I26d DESCRIBE HOW INJURY OCCURRED I Accident Undele I —ned M Swcide I] Pending 26e INJURY AT WORK 261 PLACE OF INJURY - At tome. farm. street 'act,, 26g LOCATION STREET OR R F.0 NO CITY OR TOWN STATE ❑ Homicide Inxest,gakon ❑ ❑ office building. etc lS, Y) Yes No I 27a DATE OF DEATH (Mp.. Day Yr) 28a DATE SIGNED (MO Day YO 28b TIME OF DEATH I / J Z... Y ¢ M 27b7b DATE SIGNED, (MO. Day Yr) 27yc. TIME OF DEATH 28c PRO NOUNCED DEAD !MO Day. Y./ 26d. PRONOUNCED DEAD (hburl H E d a / 27tl To the best of my knowledge. death occurred a -me. dale antl place no due to the 28e. On the basis of examination and or investigation, n my opinion death —ned at b .- c p I , auselsl stated. i ,,� the time, date and place and due o the causes) stated (Si nature and Title) ► IS Qnature and Tdlej It 29. DID TOBACCO USE CONTRIBUTE TO THE DEA ? 7 30 a HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREDn 30.b WAS CONSENT GRANTED' (� ❑ �,� ❑ YES NO UNKNO ❑ YES / 1�NLI YES I`y(' NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( (Type a rnnq N� 1, �e-\� 1 I -iti IV m, cl. - icroea �— 321b DATE FILED BY REGISTRAR lbo, Day Yt)