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4 f t 1 STATE OF NEBRASKA 20053573 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL -k71 D_ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST _.WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE�� a,5 _ a`' Z EY s CPQPER .0 N 0 2 2005 ASS/STANT �ISRAR LINCOLN, NEBRASKA NEALTHAN11,00 AA &OW/CES 1 O O O 7 ( STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT c CERTIFICATE OF DEATH �5 06036 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Day. Yr.) Lavern Edward Reiners Male May 21, 2005 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 8a, AGE -Last Birthday 5b, UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Adams County, Nebraska (Yrs.) MOS. DAYS H MINB 63 OURS Mav 12, 1942 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH 507 -54 -2530 HpsPIrAL; 8b. FACILITY -NAME (If not institution, give street and number) 43860 Rd. 759 8c. CITY OR TOWN OF DEATH (Include Zip Code) Lexington 68850 99.RESIDENCE•STATE 9b COUNTY Nebraska I Dawson 9d. STREET AND NUMBER 4.3860 Rd. 759 10a. MARITAL STATUS AT TIME OF DEATH UMarriod ❑ Never Married ❑ Married, but separated U Wldowed U Divorced ❑ Unknown ❑ Inpatient 0110: ❑ Nursmg Home/LTC LJ Hospic3 Faclllty U ER /Outpatient $J Decedent's Home ❑ DOA ❑ Other 8d. COUNTY OF DEATH Dawson 9c CITY OR TOWN Lexington 9s. APT. NO 9f. ZIP CODE T 9g. INSI - "_.._.._..__..IM _.. DE CITY LIMITS 68850 0 YES 30 NO 10b. NAME OF SPOUSE First, Middle, Last, Suffix If wife, give maiden name. Joann Gruber 11. FATHER'S -NAME (First, Middle, Las I, Suffix) 12. MOTHER'S -NAME (First Middle Malden Surname) August Reiners Florence Benker 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. 14a. INFORMANT-NAME (Yes,no,orunk.) No Joann Reiners 15. METHOD OF DISPOSITION 16a. EMBAL ER-SIGNATURE MBurial. ❑Donation �� • Cremation ❑ Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION ❑Removal ❑ Other (Specify) Greenwood Cemetery 14b. RELATIONSHIP TO DECEDENT Wife 166 LICENSE NO. 16c. DATE (Mo., Day Yr. I #1353 May 26, 2005 CITY/TOWN STATE Lexington Nebraska 17a. FUNERAL HOME NAME AND MAILING AD09ESS (Street, City or Town, Slate) 17b. Zip Code Reynolds -Love Funeral Home 106 W. 8th St. Lexington, Nebraska 68850 18. PART I. Enter the chain of events- Alseases, injuries, or compllcatlons- -that directly caused the death. DO NOT enter terminal events such as cardlac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines It necessary, I IMMEDIATE CAUSE: I onsef to death IMMEDIATE CAUSE (Final (a) Heart Attack , Immediate disease or condition resulting DUE T0, OR AS A CONSEQUENCE OF: I onset to death In death) Sequentially list conditions, if (b) any, leading to the cause listed -- _ " - N ._ ....... ......._..... DUE Tp, OR AS A CONSEQUENCE OF: on line a. Enterthe UNDERLYING CAUSE (disease or Injury that Initiated (o) the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF LAST I I I I onsetto death I I ansgl tc death I (d) I 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditlons contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER ..._ ................. 20. IF FEMALE: 21 a. MANNER OF DEATH Ll Not pregnant within past year W Nelural ❑ Homicide ❑ Pregnant at time of death ❑ Accident❑ Pending Investigation ❑ Not pregnant, but pregnant within 42 days of death ❑ Suicide ❑ Could not be determined Ll Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown If pregnant within the parr year 22a. DATE OF INJURY (Me., Day, Yr) 2fdw. -T1M6 N/A , N/A �2eNDJE�SCRIBE HOW INJURY OCCURRED ❑ YES 3]NO N/A 221, LOCA110N OF INJURY - STREET & NUMBER, APT, N0, CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) r OR CORONER CONTACTED? 241b. TIME OF DEATH 3 XJ YES U NO 21 b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? ❑ Driver /Operator 23c.TIME OF DEATH. _ 24c. PRONOUNCED DEAD (Mo., Day, Yr,) 24d. TIME PRONOUNCED DEAD ❑ YES b1 NO ❑Passenger Ewa= May 21 2005 LU Pedestrian e ra 23d.To the bast of my knowledge, death occurred at the time, date and place �' '1r $ 51 = $ 24e. On the basis of examination and /or Investigation, in my opinion death occurred at - and due to the cause(s) stated. (Signature and Title) F 21d. WERE AUTOPSY FINDINGS AVAILABLE TO U Other (Specify) 25. NO TOBACCO USE CONTRIBUI'ETOTHE DEATH? COMPLETE CAUSE OF DEATH? 26b. WAS CONSENT GRANTED? ❑ YES ❑ NO ❑ PROBABLY N UNKNOWN ❑ YES ❑ NO 221, LOCA110N OF INJURY - STREET & NUMBER, APT, N0, CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) r 24a. DATE SIGNED (Mo., Day, Yr.) 241b. TIME OF DEATH 3 tua Ma 25, 2005 Approx. 1:00 pT V 23b. DATE SIGNED (Mo., Day, Yr.) 23c.TIME OF DEATH. _ 24c. PRONOUNCED DEAD (Mo., Day, Yr,) 24d. TIME PRONOUNCED DEAD E X m Ewa= May 21 2005 8:30 P. m e ra 23d.To the bast of my knowledge, death occurred at the time, date and place �' '1r $ 51 = $ 24e. On the basis of examination and /or Investigation, in my opinion death occurred at - and due to the cause(s) stated. (Signature and Title) F p u the time, date and plaid due 1 cause(s) stated (Signature and Title) 25. NO TOBACCO USE CONTRIBUI'ETOTHE DEATH? 26a. HAS ORGAN OR TISSUE DONATION CONSIDERED? 26b. WAS CONSENT GRANTED? ❑ YES ❑ NO ❑ PROBABLY N UNKNOWN ❑ YES M NO Not Applicable If 26a Is NO ❑ YES U NO 27 NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (TypeorPrint) Elizabeth Waterman, Dawson County Attorney 700 N. Washington St. Lexington, Ne.6885 26a, REGISTRAR'S SIGNATURE _ 6I� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I MAY 2 7 Inns