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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON -FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC-" E( iICH HIS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />ANLEY.S. COWiM
<br />3/28/2005 200503701 _.
<br />ASSISTANT STATE- ROGISTRAlf-
<br />LINCOLN, NEBRASKA HEALTH AND#&M(A SERVICES-§YSTf7lT
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SET V"_1M' �Ti4?�E� SUPPE3ILT
<br />VITAL STATISTICS =
<br />-- = =
<br />_ -...
<br />CERTIFICATE 12979 FICATE OF DEATH _ =; '- -
<br />AMk FIRST MIDDLE LAST Z Bey S" ATE OF DEATH fMonm. Day. Year)
<br />nne Kay Richter Female 11 -25 -2004
<br />�4.CITY �AND
<br />E OF BIRTH 111 not in U.S.A.. name country/ 58. AGE - Laat BiMdey UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Month, Day. Year)
<br />Hastings, NE (Vrs'I 4 5b. MOB. I DAYS 5c. HOURS' MINS.
<br />3 -01 -1956
<br />7. SOCIAL SECURTIY NUMBER Its PLACE OF DEATH
<br />HOSPITAL: ❑ Inpatient OTHER: ❑ Nursing Home
<br />506-20-2627 -
<br />Bb. FACILITY -Name (if not rhsrimaan, give street and number) 0? ER Outpatient ❑ Residence
<br />Mary Lanning Memorial Hospital El DOA ❑ Other -
<br />8c CITY. TOWN OR LOCATION CF DEATH 8d. INSIDE CITY LIMITS ae. COUNTY OF DEATH
<br />Hastings Yea ® No ❑ Adams
<br />9a, RESIDENCE -STATE 96. COUNri gp, CITY, TOWN OR LOCATION 9d. STREET AND NUMBER (fnctuding2PPCads/ 9e. INSIDE CITY LIMITS
<br />68832
<br />NE Hall Doni hen 1 5462 S. Blain Yea ® Np ❑
<br />10. RACE - (e.g., White, Slack, American Indian, 11. ANCESTRY (e.g.. Italian, Mexican. German, etc) 12. ® MARRIED ❑WIDOWED 13. NAME OF SPOUSE //f wile, give maiden name)
<br />etc.) (Specify) White t e (Specify/ NEVER
<br />it American DIVORCED Roger .Richter
<br />14a. USUAL OCCUPATION /Give kind Df work dare owing moyf 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest glade completed(
<br />otworkingll/e,evenilretiredl
<br />Elementary. or Secondary l0 -121 Collagen- 4vey•I
<br />Care Giver Mental/ Handicapped 1 12
<br />16. FATHER - NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Richard Uden Delma Kleier
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? 1ga. INFORMANT - NAME
<br />(Yes, no. or unk.) pf yes. give war and dates of services)
<br />NO
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R,F,D. NO., CITY OR TOWN. STATE. ZIP)
<br />15462 S. Blaine, Doniphan, NE 68832
<br />20.E MER - SIGNATURE & LICENS NO,
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE
<br />21c. CEMETERY OR CREMATORY NAME --
<br />.
<br />Burial ❑Removal
<br />11 -30 -2004
<br />Greenwood Cemetery
<br />2 a. M - NAM
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Fnd-Wilson
<br />Br Funeral Hom
<br />❑cremation Donation
<br />Trumbull NE
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO, CITY OR TOWN. STATE, ZIP)
<br />505 N. Bellevue, Hastings, Ne 68901
<br />23. IMMEDIATE CAUSE (ENTER ONLY NE CAUSE PER LINE FOR 1,11. (b). AND (cl) Interval between onset and death
<br />PART 7 /
<br />J" /�n`l.
<br />'.7 • n O�
<br />�U�`rl L-C� (./ /tip'.. {_ I
<br />C_
<br />181 .
<br />I
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />1
<br />@I I
<br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death
<br />Icl I
<br />I
<br />OTHER SIGNIFICANT CONDITIONS - Corldtlions contributing to the death but not related PART
<br />PART
<br />III IF FEMALE. WAS THERE A
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />II
<br />IN THE PAST 3 MONTH$?
<br />EXAMINER DR CORONER?
<br />(Ages
<br />10 -541 Yes No
<br />Yea No
<br />Yes No
<br />28a.
<br />286. DATE OF INJURY /Mo.. Day. Yc/
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident � Undetermined
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />261, PLP.C� QF.INNJURY � �� ,farm, Street. factory
<br />28g, LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yea No
<br />❑ ❑
<br />offfifice 'id In etc.
<br />27a. DATE OF (W,. DDa]y, YW
<br />28a. DATE SIGNED (Mo.. Day. Yc)
<br />28b. TIME OF DEATH
<br />%DEATH
<br />M
<br />27b, DATE SIGNED /MO., Day. Vr)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD lMo.. Day, Yr.)
<br />28d. PRONOUNCED DEAD (Hour)
<br />H
<br />�� --
<br />M
<br />8
<br />$�
<br />27d. To the best of my knowletl"ath occurred at the time, date and.pa¢e and due to the
<br />cause(sl -
<br />28e, On ;he basis of examination and,or investigation, in my opinion death occurred at
<br />9
<br />° cP 8
<br />stated. j �••
<br />L ' J
<br />�t' /4�'
<br />ri n
<br />the lime, date and place and due 10 the causefs) stated.
<br />ISi nature and Title) l i • lr'�/
<br />IS nature and n0e ►
<br />29. DID TOBACCO USE CONTRIBUTE TO THE 1111? 30,a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />❑ YES ❑ NO V I UNKNOWN
<br />YES ❑ NO
<br />❑ YES ® NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTO RNNEEY) /Type cr Print)
<br />Dennis D. Hatch MD 715 NA St Jose H NE 1
<br />32a. REGISTRAR
<br />326. DA E FILED BY REGISTRAR (Mo.. Day, Yr,)
<br />111V 3 ® zoos
<br />7► •
<br />Lot One (1), Poverty Flats Subdivision, Hall County, Nebraska,
<br />
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