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Lots Five (5), Six (6) and Seven (7), Block Three (3), Second Addition to Cairo, Hall County, Nebraska C
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FWANCE AND SUPPORT
<br />2 0 0 5 0 4 4 0 2 VITAL STAMSMS 313:1 ,S8
<br />CERT IFICATE OF DEATH
<br />N T - NAME FIRST MIDDLE LAST
<br />2 SEX
<br />n
<br />li-7 Arthur John u z n
<br />-•.a
<br />C:> -4
<br />a CIY AND STATE OF BIRTH /Mid V US.A. /ww ota.Wy/
<br />56. AGE - 1"B44"
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />a DATE OF BIRTH ,Ma1Fr Dey YA.rI
<br />Milford. Nebraska
<br />(YR.1 Sb
<br />92
<br />Mol,. DAYS
<br />SC. HOURS Mf1S
<br />10ctober 17 1911
<br />7 SOCIAL SECURTIY NUMBER
<br />8e. PLACE OF DEATH
<br />710 -03 -7060
<br />M
<br />;.
<br />mn
<br />Z
<br />n=
<br />Q:
<br />s
<br />M COUNTY OF DEATH
<br />-
<br />o
<br />Douglas
<br />99 RESIDENCE • STATE
<br />9b. COUNTY
<br />fl:. CITY. TOWN OR LOCATION
<br />W. STREET AND NUMBER lfge.I"Zp Caen f• INSIDE CITY LIMIT$
<br />Nebraska
<br />as
<br />Omaha
<br />710 S. 108th St. #303 Yq ®� ❑
<br />10. RACE - 1..4. Mww. Bac.. Am.rlgn Men.
<br />11. ANCESTRY lag. Nrfen. MoxwAiL G.mwi. Mel
<br />12. © MARRIED ❑ WIpQWED
<br />13 NAME OF SPOUSE 4 trM 91M MA~
<br />� �-
<br />Cri
<br />(Sp.c•lII
<br />ON
<br />i
<br />�'
<br />1aa USUAL OCCUPATION ND OF BUSINESS WpU5TRV
<br />1S EDUCATION MOO-* odtN91'" e V11111111 cop
<br />;,
<br />M mM wy or Sgax ly lo- 121 Cefp. 11 -,1 d 5•
<br />IB FATHER. NAME FIRST MIDDLE L&V 17
<br />MOTHER FIRST MIDDLE MA10EN SURNAME
<br />David Stutzman
<br />Emma Jausi
<br />�-
<br />EVER IN U.S. ARMED FORCE$?
<br />1YL INFORMANT . NAME
<br />1Yw no or t/tLl
<br />No
<br />�,
<br />U)
<br />Ifb. INFORMANT MAR NO ADDRESS (STREET OR FLF.0 NO.. CITY OR TOWN. STATE 21P)
<br />Tf�
<br />505 Kimball Road Dannebrog, NE 68831
<br />20. EMBALMER • SIGNATURE f LICENSE ND.
<br />211 METHOD OF DISPOSITION
<br />21b. DATE 21c,
<br />CE VERY OR TORY NAME
<br />Hr e +leo mann�Dworak
<br />❑ a,�, ❑ „.,�„,,
<br />June 14, 2004
<br />M FUNERAL HOME NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />A fel Funeral Home
<br />®`'""'°" ❑Donow
<br />2ft FUNERAL HOME ADDRESS (STREET OR N.F.D. NO.. CITY OR TOWN. STATE, 21P1
<br />411 West 11th Street Wood River NE 68883
<br />M. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE ",al— I4 AND (ell .eMr41 bee.eF't drMn and death
<br />to
<br />I
<br />"I
<br />DUE TO, OR AS A CONSEQUENCE OF V e.arval bsw~I onm am death
<br />d, s r S years
<br />DUE TO. OR AS A CONSEQUENCE OF I 1111srvy bett..en pun aM death
<br />lol cr yea r s
<br />(CI /yl y t. s /Gti
<br />PART OTHER SIGNIFICANT CONDITIONS • cw**uMq b daft big da bug no t.IMed PART
<br />N IF FEMALE WAS THERE A 24
<br />ALIT OP$
<br />25. WAS CASE REFERRED TO MEDICAL
<br />a
<br />N THE PAST 3 MONTW
<br />"AMER OR CORONERy
<br />1Ag.e
<br />to-5 1 Ye. No
<br />Yea No 7x
<br />Yoe NO
<br />0
<br />Lots Five (5), Six (6) and Seven (7), Block Three (3), Second Addition to Cairo, Hall County, Nebraska C
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FWANCE AND SUPPORT
<br />2 0 0 5 0 4 4 0 2 VITAL STAMSMS 313:1 ,S8
<br />CERT IFICATE OF DEATH
<br />Ire. � • -e..� -� •• j"� I
<br />T"h:CgCt4r14* thla docvsent to be a true copy of an original record on Mils vit11 vital
<br />%ittsticyXI; Dig i* Co'tMtr iealth apartment. Owaha. Nebraska. Card -fled copies' wust have
<br />atr�Lsad s 1 1a pi at #,�to the loft. 164praductiens of thin grace eartilicats a� t
<br />��i•.eop ",fir' <� .`t^.
<br />�• °N.i swd�. JUG.. Registrars
<br />Ii..•
<br />N T - NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3. DATE OF DEATH ,Mali Dry Y"O
<br />li-7 Arthur John u z n
<br />une 12 2004
<br />a CIY AND STATE OF BIRTH /Mid V US.A. /ww ota.Wy/
<br />56. AGE - 1"B44"
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />a DATE OF BIRTH ,Ma1Fr Dey YA.rI
<br />Milford. Nebraska
<br />(YR.1 Sb
<br />92
<br />Mol,. DAYS
<br />SC. HOURS Mf1S
<br />10ctober 17 1911
<br />7 SOCIAL SECURTIY NUMBER
<br />8e. PLACE OF DEATH
<br />710 -03 -7060
<br />HOISPICAL [] ""a." OTHER. E] Iii lier
<br />❑ EA Oup..R. ❑ Rnld.nc.
<br />fb. FACILITY - Nam. / /r1aravAmow>r.NandnlrrgpnT
<br />•
<br />Hospice House 7415 Cedar Street
<br />❑ OCA, ® 01wAlvw* Hospice House
<br />fc CITY TOWN OR LOCATION OF DEATH Sy INSIDE CITY LIMITS
<br />M COUNTY OF DEATH
<br />Omaha I Y.a ®Ib ❑
<br />Douglas
<br />99 RESIDENCE • STATE
<br />9b. COUNTY
<br />fl:. CITY. TOWN OR LOCATION
<br />W. STREET AND NUMBER lfge.I"Zp Caen f• INSIDE CITY LIMIT$
<br />Nebraska
<br />as
<br />Omaha
<br />710 S. 108th St. #303 Yq ®� ❑
<br />10. RACE - 1..4. Mww. Bac.. Am.rlgn Men.
<br />11. ANCESTRY lag. Nrfen. MoxwAiL G.mwi. Mel
<br />12. © MARRIED ❑ WIpQWED
<br />13 NAME OF SPOUSE 4 trM 91M MA~
<br />eb:.l Is.yl
<br />White
<br />(Sp.c•lII
<br />NEVER DIYORDED
<br />es Stutzman
<br />1aa USUAL OCCUPATION ND OF BUSINESS WpU5TRV
<br />1S EDUCATION MOO-* odtN91'" e V11111111 cop
<br />d 1Mra Yi/. IYe71 /ryY.el
<br />71-
<br />ia�orer Agriculture
<br />M mM wy or Sgax ly lo- 121 Cefp. 11 -,1 d 5•
<br />IB FATHER. NAME FIRST MIDDLE L&V 17
<br />MOTHER FIRST MIDDLE MA10EN SURNAME
<br />David Stutzman
<br />Emma Jausi
<br />18 WAS DECEASED
<br />EVER IN U.S. ARMED FORCE$?
<br />1YL INFORMANT . NAME
<br />1Yw no or t/tLl
<br />No
<br />If TO. g" •.r .N1 d.L. IN grv.1 0
<br />Charles Dennis Stutzman
<br />Ifb. INFORMANT MAR NO ADDRESS (STREET OR FLF.0 NO.. CITY OR TOWN. STATE 21P)
<br />505 Kimball Road Dannebrog, NE 68831
<br />20. EMBALMER • SIGNATURE f LICENSE ND.
<br />211 METHOD OF DISPOSITION
<br />21b. DATE 21c,
<br />CE VERY OR TORY NAME
<br />Hr e +leo mann�Dworak
<br />❑ a,�, ❑ „.,�„,,
<br />June 14, 2004
<br />M FUNERAL HOME NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />A fel Funeral Home
<br />®`'""'°" ❑Donow
<br />2ft FUNERAL HOME ADDRESS (STREET OR N.F.D. NO.. CITY OR TOWN. STATE, 21P1
<br />411 West 11th Street Wood River NE 68883
<br />M. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE ",al— I4 AND (ell .eMr41 bee.eF't drMn and death
<br />PART
<br />I
<br />"I
<br />DUE TO, OR AS A CONSEQUENCE OF V e.arval bsw~I onm am death
<br />d, s r S years
<br />DUE TO. OR AS A CONSEQUENCE OF I 1111srvy bett..en pun aM death
<br />lol cr yea r s
<br />(CI /yl y t. s /Gti
<br />PART OTHER SIGNIFICANT CONDITIONS • cw**uMq b daft big da bug no t.IMed PART
<br />N IF FEMALE WAS THERE A 24
<br />ALIT OP$
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />N
<br />N THE PAST 3 MONTW
<br />"AMER OR CORONERy
<br />1Ag.e
<br />to-5 1 Ye. No
<br />Yea No 7x
<br />Yoe NO
<br />2611
<br />28b . DATE OF NARY AW- D.Y. Yt J
<br />2Bt. HOUR OF INJURY
<br />28d DESCRIBE HOW WAIM OCCURRED
<br />❑ Acca t ❑ Uttoel.rmr"
<br />M
<br />❑ S.O. ❑ Pw m-g
<br />28.. NjURY AT WORK
<br />281. PLAC "A �At hp1y. Wm. W@K W=y
<br />2% LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE
<br />❑ rlptrllpd. Inv.a.gobon
<br />Y.e ❑ WE]
<br />afu Sp.CtYI
<br />278 DATE OF DEATH (AA7. Dar Yr.)
<br />293. DATE SIGNED A*. Dry Yi I
<br />2fb TIME OF DEATH
<br />a=
<br />June 12 2004
<br />M
<br />27b DATE STONED 1. DAY Y, 1
<br />TIME OF DEATH
<br />2fe. PRONOUNCED DEAD /Ab.. D4, Ycl
<br />2fG PRONOUNCED DEAD 1HO-1
<br />C
<br />€..
<br />127c
<br />11:18.P M
<br />M
<br />27.1 To We bW d my Mrw4dga d ag e1. Ylne, dra plat. MM blf,��/u
<br />2ft On tta bean d oamnNcin and a nva poxim m Iny opr.on dsam accv fd N
<br />e
<br />°
<br />r
<br />CAUM31 500d, C,�r^��
<br />3
<br />to eme, dIM end Phow ano dub 2D to cauwsi smd.
<br />. and T-41 A
<br />I &V rife
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED+ 3017
<br />WAS CONSENT GRANTEDT
<br />1:1 YES X NO ❑ UNKNOWN
<br />❑ YES IR NO
<br />❑ YES ❑ NO
<br />31 NA ME AND ADDRESS OF CTWWIPYKIAK OONERPNYSC W COUNY ATTOFMYI ITp. w PMW
<br />P L_ *VE U 91 �7 97 ►
<br />32'.. gEG15TRAR
<br />32b. DATE FILEJUN REGISTRAR AM1
<br />Ire. � • -e..� -� •• j"� I
<br />T"h:CgCt4r14* thla docvsent to be a true copy of an original record on Mils vit11 vital
<br />%ittsticyXI; Dig i* Co'tMtr iealth apartment. Owaha. Nebraska. Card -fled copies' wust have
<br />atr�Lsad s 1 1a pi at #,�to the loft. 164praductiens of thin grace eartilicats a� t
<br />��i•.eop ",fir' <� .`t^.
<br />�• °N.i swd�. JUG.. Registrars
<br />Ii..•
<br />
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