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<br />WHEN a'i jIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA WEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD 'BN.OPCE- WITl•1
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA TISTICS $FCnO1W WWH IS-;,-
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE C rl-
<br />FEB 2 4 2000 2 0 0 5 0 5 9 J ASSISTAN "ra� GOT OP
<br />LINCOLN, NEBRASKA HEALTH AND HUMANSERVICES SYSTEM"
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES F'NANCEW_ ti SUPPORT
<br />VITAL STATISTICS - -
<br />CERTIFICATE OF DEATH
<br />- 3 DA OF DEATH IM0,1M tier Year;
<br />-- LAST
<br />— _........_-- ....... MIDDLE ..
<br />1 DF:(:F I]EN1 NAME. FIFl4T
<br />Albert Carl Quandt Male February 14, 2000
<br />( IF s 3 day UNDER 1 YEAR _ UNDER I DAV 6. DATE OF BIRI H (Month. Dav Year)
<br />a CITY ANU STATE OF BIRTH ill not in Us. A.. narrly country)
<br />c HUVRS MIN$ 19 36
<br />Grand Island, Nebraska Sa. AUE -Last Binh October 17,
<br />50. MOS DAYS
<br />HOSPITAL'. Inpatient — _..._... —....
<br />7 5(1(.IAL SECURTIV NUMBER r � Be . PI A(,E OF DEATH
<br />® tient OTHER ❑ Nursrng Home
<br />505 --54 -3920 ER Outpatient ❑ El Res,dence
<br />- - —
<br />8b FA(:ILITY Name yinotmsfrtufion, give street and numbef)
<br />❑ Don ❑ Other rsner:rlyr _._.
<br />St. Francis Medical Center _
<br />-
<br />ac CITY 1OWN OR LOCATION OF DEATH _ Dd WSIDE CITY LIMITS_ reCOUNTY OF DEATH
<br />Grand island _. __ Hall __ :geWN�.-
<br />Yes No
<br />9a RESIDENCE -STATE m 9b COUNTY
<br />9c CITY, TOWN OH LOCATION 9d STREET AND NUMBER (tnci,,Wr42 Code)
<br />Nebraska Hall Grand Island 3620 Summer Dr. 68803 �Yesk] No ❑
<br />tD HACE - (e.g� While Black. American Indian 11 ANCESTRY le g halian. Mexican, German. etc)
<br />12 MARRIED ❑ WIDOWED 13. NAME OF SPOUSE llf wife. give maiden name)
<br />etc )ISPeafy) (Specify) NEVER nDIVCACED Dianne Bookman
<br />White German /American M RRI _ L.J
<br />Ny�dpg�rN 14b KIND OF BUSINESS INDUSTRY 15 EDUCATION (Specify only highest grade completed) —
<br />14. USUAL OCCUPATION /Give 1cf1d6v Mn6�u Pt( (Lost Elementary or Secondary (012) College. I1 4 or G•I
<br />o /wnrA,ng lire. even ArenreoJ Cl l:ll11IIII 4 12th Grade
<br />Fabrication Division Building Construction
<br />16 FAfHEFl-NAMC _ FIRST MIDDLE LASY 17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Reinhardt William Aufzust uandt Paula Katherine -Martha _.._ Scher_zberg__._.
<br />CR IN 11 . A ;MED FORCES? Q
<br />1 R Wn5 U6CEA °ELI FVllf yes 9've war and dates of services)
<br />)Ves 'ur. or __ •. yISTREE7 OR fa F 0 NO.. CITY OR OTOWNNSTA NAME
<br />Yes ____ Jul 1 1959 -Ma 3 1961 Dianne uan t
<br />1dh `VFOryMANT MA,UNG ADDRESS
<br />3620 Summer Dr., Grand Island, Nebraska 68803 _ -
<br />-- 21a METHOD OF DISPOSITION EF�L�b TE 21c CFMETERYOFlCHEMATURY NAME
<br />UOFNSC NO ❑Rempral . 1. 7, 2000 Grand Island City Cemete
<br />RE
<br />- -" J• 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />22a FUNERAL. HOME NAME
<br />❑Cremation ❑Donalon Grand Island, Nebraska ._....
<br />Livingston- Sondermann F.H. -
<br />22b FUNERAL HOMF ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, YIP)
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050 Interval between onset and deals —
<br />23 IMMEDIATE C SE [// (DENTE /R�ONLY �ONE CAU�$E PER LINE FOR lat. Ib). AND let) i
<br />K PART /�C�[/�'�� /T�/fJY( L.V>V✓G ".l.0
<br />(al LW ✓� Interval between onset and d0,1Th
<br />DUE TO OR AS A CONSFOVENCE OF
<br />I
<br />I Interval between onset and neat,
<br />nI,lc 10, cN' AS A (',0N1,;E0UFNCE OF - I
<br />�)
<br />OTHER SIGNIFICANCoT/Co' DITION/,SS Conditionn)•s�contributing
<br />)(to the deals but npjpreI e � PgEGNANCY NATHE MAST 3 MONTHS AUTOPSY {5 F AMCINER OR CORONER' MEDICAL
<br />PART O I ✓ • J , I [ / ♦ 4 �+ t d CV P✓I _M
<br />PART NU lly' 7�
<br />II 1D.54) Ves No ✓Is Np �.,nr
<br />26a 26b DATE OF INJURY (Mo.. Day Y, it 26c HOUR OF INJURY 26d DESCRIBE HOW IN,Il1Hr OCCURRED
<br />T..
<br />Ac ,dem U,oetern�ine° M
<br />,,TREE'! OR R.F U. NO. CITY OR TOWN - - - -
<br />_ �......._ � WN STATE.
<br />r l `)urc:Ide V °nnury 25e INJU AT WORK 26f D C. bu l' INJURY At h Specify m7 larm, street. factory 269. LOCATION
<br />F 1 Horne: de In,e; rganon
<br />yes E, No -- --
<br />" "" 28a DAIS SIGNED (M, . Day Yr) 28b TIME OF DF. AT11
<br />27a Un YF OF DEATH /MU Day Yr:)
<br />?- /Y— p0 yaw M
<br />a 77n. DATE. SIGNED IMO. Day Yr.l 27t TIME OF DEATH r ' 28c. PRONOUNCED DEAD IMO Day. Yr,J 28d PRONOUNCED 1 0 /Hour)
<br />K 27d To Ise be51 0l my knnwletlge de the time, date and place and die �o Iha r° 0, 28e. On the basis of examination andror Investigation, In my opinion death occurred al
<br />( -annd ue t the time. date and place and due to the cause(s) stated.
<br />.t" causelv'. stated
<br />(S� nature and tine) ► Signature and Title ►�
<br />. 29 DID fOB(S, n USE CON le) lix E TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 3i.b WAS CONSENT GRANTED°
<br />YES NO ❑ YES NO —
<br />❑ YES NO UNKNOWN ,,,�_.....,._ _�.....
<br />Fat ,NAME AND AMEE5_S OF CERTIFIER (PHYSICIAN, CORONER 5 PHYSICIAN OR COUNTY ATTORNEY) ,(iype_or P U `� /� ,� •� C� / (/��
<br />FILED BY REGISTRAR (Mo. . Day Yr)
<br />k /j Mo Y
<br />32b DE .
<br />HEG15TRAR �, FEB 2 2 2000
<br />
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