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Lot Six (6) in Knickrehm Eighth Addition to the City of Grand Island, Hall
<br />County, Nebraska.
<br />WHEN THIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, ff CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD Ohl. FI(E`W1TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEGTlOWW"CH 4
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />00 2UO2 ASSISTANTSTATEREGISTRAm
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN 3ERVICEs_SYSTPjw-_
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCEAND SUPPORT
<br />VITAL STATISTICS 0 2 11483
<br />CERTIFICATE OF DEATH
<br />I DECEDENT - NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3. DATE OF DEATH (Morita Dal, Yearl
<br />Duane Allan Reichert
<br />Male
<br />September 24, 2002
<br />4 CITY AND STATE OF BIRTH /lfdot it U S A. name country)
<br />5a AGE - Last &nhday
<br />UNDER 1 YEAR
<br />—i
<br />6. DATE OF BIRTH IMOnet, Dav Yearl
<br />MOS DAYS
<br />Sc HOURS MINS
<br />Stockham, Nebraska
<br />(Yr561 51b
<br />September 28, 1940
<br />7 SOCIAL SECURTIY NUMBER
<br />8. PLACE OF DEATH
<br />® Inpatient OTHER ❑ Nursing Home
<br />M U,
<br />HOSPITAL
<br />CD
<br />li"1
<br />Bb FACILITY - Name 11(nol msfifution, give street and numbep
<br />Good Samaritan Hospital
<br />❑ DOA ❑ OtherlSPecd, --
<br />8c CITY TOWN OR LOCATION OF DEATH
<br />8d INSIDE CITY LIMITS
<br />Be COUNTY OF DEATH
<br />Kearney
<br />Yes ® No ❑
<br />Buffalo
<br />9a RESIDENCE - STATE
<br />CD
<br />9c. CITY. TOWN OR LOCATION
<br />9d STREET AND NUMBER /Including Zip Co�e� o O 1 9e INSIDE CITY LIMITS
<br />Nebraska
<br />(71
<br />Grand Island
<br />2211 Maplewood Pl. ' Yes ® "° ❑
<br />10 RACE leg., White. Black American Indian
<br />11. ANCESTRY leg Italian. Mexican. German, etc)
<br />12. ® MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE tll wde give maiden name)
<br />1
<br />o cu
<br />ISce"") German
<br />NEVER DIVORCED
<br />Thelene Martens
<br />l
<br />t1"I
<br />S!y
<br />2n
<br />14a USUAL OCCUPATION /Give kindPf work done during most 14b
<br />N
<br />C;
<br />C
<br />Elementary f2ecordary 10 -121 joeege n a or S• I
<br />1L
<br />of l k dg life, even it relrrecil
<br />Laborer
<br />Retail
<br />16 FATHER - NAME FIRST MIDDLE LAST 17
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Vern Reichert
<br />Vera Roemmich
<br />18 WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a INFORMANT- NAME
<br />Yes no or unk.l III yes give war and tlales of Services)
<br />No
<br />Thelene Reichert _
<br />19b INFORMANT MAILING ADDRESS (STREET OR R F D NO. CITY OR TOWN STATE. ZIPI
<br />2211 Maplewood Place, Grand Island, NE. 68801
<br />20 EMBALMER - SIGNATURE 8 LICENSE NO
<br />el a METHOD OF DISPOSITION
<br />21b DATE 21c CEMETERY OR CREMATORY NAME
<br />,�l{.
<br />I e '- L2Z7
<br />® Buda, ❑ Removal
<br />Sept. 28, 2002 Westlawn Memorial Park
<br />22a FUNERAL HOME - NAME
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes
<br />1:1 Cremation ❑Donalon
<br />Grand Island, NE.
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />1123 West Second, Grand Island, NE. 68801
<br />23 IMMEDIATE CAUSE •- (ENTER ONLY ONE CAUSE PER LINE FOR ,al (b). AND Icll ) Interval between onset and dealt,
<br />PART
<br />I
<br />tat
<br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset and neam
<br />1 n
<br />/�/
<br />i �� -i'v. /— I
<br />Icl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contnbuting to the death but not related P T III IF F �YN LE. WAS THERE A v' 24 AUTOPSY �-' 25 WAS CASE REFERRED TO MEDICAL
<br />MONTHS? EXAMINER OR CORONER'
<br />.�,
<br />(Ages 10 -5Yes No Ves No Yes No
<br />26a
<br />26b DATE OF INJURY Mo. Day Yii 26c /HHOUR OF INJURY 260.DESCRIBE HOW INJURY OCCURRED
<br />Z'ACC.tlent Undetermined
<br />/
<br />3©
<br />Suicide Pendmg
<br />26e INJU V AT WORR LA6f PLACE F INJUURY -St home. lar street factory 26g LOCATION STREET R D NO CITY OR TOWN STATE
<br />Homicide investigation
<br />Yes ❑ Nd building, (Specify) `
<br />2211 Ma lewood Pl. Grand. Island, NE
<br />27a. DATE OF EATH ! -Day Ycl
<br />28a DATE SIGNED [Mo. Day Yrl
<br />28b TIME OF DEATH
<br />�/v v
<br />a>
<br />M
<br />` CZ
<br />�i
<br />$
<br />27b DATE SIGNED r / Day YU
<br />27c TIME OF DEATH
<br />(�
<br />20d. PRONOUNCED DEAD /Noun
<br />Y
<br />LD '
<br />I
<br />M
<br />"�
<br />—j
<br />27tl TO Itte best OI m knOwle e. deaM occurred al he time, d did 012ce and due 10 the
<br />28e Qn the basis OI d place an and Or the causedrl, In my Opinion death occurred al
<br />the emit. date and dace and due to the causelsl slated.
<br />o
<br />_ <
<br />¢
<br />causelsl stated. eO
<br />ISr nature and Tnlel ► l
<br />Cn
<br />(Sr nature and Title) 0 --
<br />29 DID TOBACCO USE CONTRIB E TO THE DEATHIJ
<br />90 a HA ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRAN I LU
<br />❑ YES [114. F] UNKNOWN
<br />❑ YES © Np
<br />❑ YES ❑ NO —
<br />31 NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( (Type o, Pnml
<br />200211676
<br />C/)
<br />32b DATE FILED BV REGISTRAR /Mo. Day YcJ
<br />32a REGISTRAR
<br />r (j�
<br />0CT1ALaV-- -
<br />t
<br />Lot Six (6) in Knickrehm Eighth Addition to the City of Grand Island, Hall
<br />County, Nebraska.
<br />WHEN THIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, ff CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD Ohl. FI(E`W1TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEGTlOWW"CH 4
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />00 2UO2 ASSISTANTSTATEREGISTRAm
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN 3ERVICEs_SYSTPjw-_
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCEAND SUPPORT
<br />VITAL STATISTICS 0 2 11483
<br />CERTIFICATE OF DEATH
<br />I DECEDENT - NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3. DATE OF DEATH (Morita Dal, Yearl
<br />Duane Allan Reichert
<br />Male
<br />September 24, 2002
<br />4 CITY AND STATE OF BIRTH /lfdot it U S A. name country)
<br />5a AGE - Last &nhday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH IMOnet, Dav Yearl
<br />MOS DAYS
<br />Sc HOURS MINS
<br />Stockham, Nebraska
<br />(Yr561 51b
<br />September 28, 1940
<br />7 SOCIAL SECURTIY NUMBER
<br />8. PLACE OF DEATH
<br />® Inpatient OTHER ❑ Nursing Home
<br />508 -46 -6619
<br />HOSPITAL
<br />❑ ER Outpatient 1:1 Residence
<br />Bb FACILITY - Name 11(nol msfifution, give street and numbep
<br />Good Samaritan Hospital
<br />❑ DOA ❑ OtherlSPecd, --
<br />8c CITY TOWN OR LOCATION OF DEATH
<br />8d INSIDE CITY LIMITS
<br />Be COUNTY OF DEATH
<br />Kearney
<br />Yes ® No ❑
<br />Buffalo
<br />9a RESIDENCE - STATE
<br />9b COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d STREET AND NUMBER /Including Zip Co�e� o O 1 9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2211 Maplewood Pl. ' Yes ® "° ❑
<br />10 RACE leg., White. Black American Indian
<br />11. ANCESTRY leg Italian. Mexican. German, etc)
<br />12. ® MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE tll wde give maiden name)
<br />etc l ISoecdylT -TMlte
<br />White
<br />ISce"") German
<br />NEVER DIVORCED
<br />Thelene Martens
<br />l
<br />AR
<br />14a USUAL OCCUPATION /Give kindPf work done during most 14b
<br />KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION
<br />(Specify only highest grade completed)
<br />Elementary f2ecordary 10 -121 joeege n a or S• I
<br />1L
<br />of l k dg life, even it relrrecil
<br />Laborer
<br />Retail
<br />16 FATHER - NAME FIRST MIDDLE LAST 17
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Vern Reichert
<br />Vera Roemmich
<br />18 WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a INFORMANT- NAME
<br />Yes no or unk.l III yes give war and tlales of Services)
<br />No
<br />Thelene Reichert _
<br />19b INFORMANT MAILING ADDRESS (STREET OR R F D NO. CITY OR TOWN STATE. ZIPI
<br />2211 Maplewood Place, Grand Island, NE. 68801
<br />20 EMBALMER - SIGNATURE 8 LICENSE NO
<br />el a METHOD OF DISPOSITION
<br />21b DATE 21c CEMETERY OR CREMATORY NAME
<br />,�l{.
<br />I e '- L2Z7
<br />® Buda, ❑ Removal
<br />Sept. 28, 2002 Westlawn Memorial Park
<br />22a FUNERAL HOME - NAME
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes
<br />1:1 Cremation ❑Donalon
<br />Grand Island, NE.
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />1123 West Second, Grand Island, NE. 68801
<br />23 IMMEDIATE CAUSE •- (ENTER ONLY ONE CAUSE PER LINE FOR ,al (b). AND Icll ) Interval between onset and dealt,
<br />PART
<br />I
<br />tat
<br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset and neam
<br />lot
<br />DUE 10. OR AS A CONSEQUENCE OF I interval betweennoon/seet and death
<br />I
<br />J ���
<br />/�/
<br />i �� -i'v. /— I
<br />Icl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contnbuting to the death but not related P T III IF F �YN LE. WAS THERE A v' 24 AUTOPSY �-' 25 WAS CASE REFERRED TO MEDICAL
<br />MONTHS? EXAMINER OR CORONER'
<br />PART ,� EGNANCTHE PAS T 3
<br />(Ages 10 -5Yes No Ves No Yes No
<br />26a
<br />26b DATE OF INJURY Mo. Day Yii 26c /HHOUR OF INJURY 260.DESCRIBE HOW INJURY OCCURRED
<br />Z'ACC.tlent Undetermined
<br />/
<br />3©
<br />Suicide Pendmg
<br />26e INJU V AT WORR LA6f PLACE F INJUURY -St home. lar street factory 26g LOCATION STREET R D NO CITY OR TOWN STATE
<br />Homicide investigation
<br />Yes ❑ Nd building, (Specify) `
<br />2211 Ma lewood Pl. Grand. Island, NE
<br />27a. DATE OF EATH ! -Day Ycl
<br />28a DATE SIGNED [Mo. Day Yrl
<br />28b TIME OF DEATH
<br />�/v v
<br />a>
<br />M
<br />�i
<br />$
<br />27b DATE SIGNED r / Day YU
<br />27c TIME OF DEATH
<br />28c PRONOUNCED DEAD IMo Day. Yr l
<br />20d. PRONOUNCED DEAD /Noun
<br />Y
<br />LD '
<br />M
<br />"�
<br />27tl TO Itte best OI m knOwle e. deaM occurred al he time, d did 012ce and due 10 the
<br />28e Qn the basis OI d place an and Or the causedrl, In my Opinion death occurred al
<br />the emit. date and dace and due to the causelsl slated.
<br />o
<br />_ <
<br />¢
<br />causelsl stated. eO
<br />ISr nature and Tnlel ► l
<br />(Sr nature and Title) 0 --
<br />29 DID TOBACCO USE CONTRIB E TO THE DEATHIJ
<br />90 a HA ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRAN I LU
<br />❑ YES [114. F] UNKNOWN
<br />❑ YES © Np
<br />❑ YES ❑ NO —
<br />31 NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( (Type o, Pnml
<br />R.R. Salumbides M.D. 21 Central Ave., Ste. #107, Kearney, NE. 68847
<br />32b DATE FILED BV REGISTRAR /Mo. Day YcJ
<br />32a REGISTRAR
<br />r (j�
<br />0CT1ALaV-- -
<br />
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