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<br />
<br />STATE OF NEBRASKA
<br />
<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 {JNE1I;E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICs..~~ Viifi!:fRo~s
<br />
<br />:::;::~~:::::~TORY FOR VITAL RECORDS_ .__~: ~i!j~:---~
<br />
<br />~fANI:__"'''''P''' .
<br />ASSISTANT'STATE FfflGKtMARc:
<br />HEALTH:ANP-'ttY~1~~~'1_~S' ..
<br />_. '~I::~'-;~~'~i2~~.~~'~.~:-:
<br />.~::,_.',".=. ,~..:::=--:: =.: j~'J":::_'~_.~::'
<br />
<br />APR 1 2 2005
<br />LINCOLN, NEBRASKA
<br />
<br />200601471
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />......w ______ . CERTIFICATE OF DEATH_ . 05 03946_
<br />1. DI:'CEDENT'S-NAME (Firs!, Mlddlo, Last Sufllx) 2. SEX 3. DATE OF DEATH (Mo., Doy, Yr.)
<br />Marvin Martin Hartmann Male April 4, 2005
<br />
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />5a. AGE-Lasl Birthday
<br />(Yrs.)
<br />
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF 8,IRTH
<br />Amherst, Nebraska
<br />
<br />80
<br />
<br />July 16, 1924
<br />
<br />
<br />Ba. PLACE OF DEATH
<br />J:l.QS.E'ITAL: 0 1.,00tIM1
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />508-28-9575
<br />
<br />Q]):!!;B: illi Nursing Home/LTC 0 Hosplco Cacilltv
<br />
<br />FACILITY-NAME (If not Inollllllion, givo slraat and nllmbar)
<br />
<br />U ER/Olltpatient
<br />
<br />CJ Dacedant's Home
<br />
<br />Beverlx' Healthcare, Park Place
<br />
<br />CJ [D\ OOlhar(Specify)________
<br />
<br />m__m__~:~;EATH
<br />
<br />90. CITY OR TOWN
<br />Grand Island
<br />J_ge_ APT NO 91. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Mlddla, Last, SIIffix) If wife, 91ve melden name.
<br />
<br />Be. CITY OR TOWN OF DEATH (Incllldo Zip Coda)
<br />
<br />Grand Island
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />
<br />9h. COUNTY
<br />Hall
<br />
<br />9d. STREET AND NUMBER
<br />
<br />.'-[99 INSIDE CITY LIMITS
<br />m YES 0 NO
<br />
<br />171ll Lariat Lane
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH CIMerrlad 0 Navar Married
<br />
<br />U Marrlad, but separaled 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Elain~ Jorgen~~n
<br />12. MOTHER'S-NAME (First,
<br />
<br />Middle, Malden Surname)
<br />
<br />Suffix)
<br />
<br />1,. FATHER'S-NAME (First, Middle, Last,
<br />Edward Hartmann
<br />13:~~~R-~N u.s. ARMED FORCES? Glv..e d..;les OISerVi~._li-~es.:...l;:;;;~~NFORMANT.NAME
<br />(Yes, no, or unk.) No Elaine Hartmann
<br />15. METHOD OF DISPOSITION - '1-6e. EMBALME I IGNATURE ~... .. -!16b. L~CE~;E. N.D.
<br />[]Burial UDone"on i ..' __ L_ /~rt!
<br />o Cremalion 0 Entombment 16d. CEMETERY, CREMATORY OR E LOCATION CITY / TOWN
<br />
<br />Myrtle
<br />
<br />Siebke
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />WJJe
<br />16c. DATE (Mo., Day, Yr.)
<br />April 7, 20():?
<br />STATE
<br />
<br />o Removal 0 Other (Speolly)
<br />
<br />Westlawn Memorial Park Cemetery,
<br />
<br />Grand Island, Nebraska
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreat, Cily or Town, Slale)
<br />Apfel Fu~eral Heme, 1123 West Second,
<br />
<br />Grand Is::':~nd,
<br />
<br />
<br />Zip Code
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />PART I. Enter the Qh~ln of Avenls--dise8sB3. injuries. Ot compllcallons--that directly caused Ihe death. DO NOT enter le~mjnal events such as cardIac arrest.
<br />resplralory arrest, or ventricular fibrillation without sllOwing Ihe etiology, DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />
<br />onsal to daeth
<br />
<br />IMMEDIATE CAUSE: Q '\
<br />
<br />(e)~'i.dJ;-.;l;>4~ Ct;OXtcfC.. l~K
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />:~)/;:Ld J1/:'_1;(;' 4:4 (!{)--yc"<-'dF,,.47 A~~~.!-'7 ?-&c:1.e~~
<br />DUE TO. OR AS A CONSEQUENCE OF: t
<br />
<br /><T'J~ 7 -"
<br />.J/V t ~.V <-.
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condlllon resulting
<br />In dealh)
<br />
<br />onset to death
<br />
<br />Sequentially list conditions, If
<br />any, leading 10 Ihe causellsled
<br />on line B.
<br />Enter Ihe UNDERLYING CAUSE
<br />(disease or Injury Ihet Inlllaled
<br />Ihe events resulting In doolh)
<br />tA';f
<br />
<br />Onset to dealh
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onsel to death
<br />
<br />(d)
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS.Conditions conlribullng to Ihe dealh but nol resulting in the underlying causa given in PART I.
<br />
<br />.(j~~5 hLt+V+~n___
<br />
<br />20. IF FEMALE:
<br />
<br />DYES
<br />
<br />NO
<br />
<br />21b.IF TRANSPORTATION INJURY 210. WAS AN AUTOPSY P RFORMED?
<br />[J Drlver/Oparalor
<br />
<br />21 a. MANNER OF DEATH
<br />p.Nelurel U Homlcida
<br />
<br />U YES
<br />
<br />--~
<br />
<br />LJ Not pregnant within past year
<br />o Pregnanl et lima 01 deolh
<br />[J Nol pregnant, but pregnant within 42 days of death
<br />o NOI pregnant, but pregnant 43 days 10 1 year before death
<br />U Unknown If pregnanl within Iho p..1 y..~~ . .
<br />
<br />o F'assenger
<br />C. Pedestrian
<br />o Othar (Spocilyl
<br />
<br />o AccidenlO Pending Inve,lIgation
<br />[J Suicide 0 Could nol be delermlnad
<br />
<br />21d. WERE AUTOPSYFiNDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />-I
<br />
<br />DYES
<br />
<br />o NO
<br />
<br />22d.INJURY AT WORK?
<br />
<br />
<br />22e.I)ATE OF INJURY (Mo., Day, Yr.)
<br />
<br />22b. TiME OF INJURY 22c. PLACE OF INJURY.AI home, farm, atree:, faclory, office building, construction sile, elc. (Speclly)
<br />
<br />m
<br />
<br />U YES 0 NO I
<br />..,._.,-_._~
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />24e. DATE ,IGNED (Mo., Day, Yr.)
<br />
<br />Nb. TIME OF DEATH
<br />
<br />23..I)ATE OF DEATH (Mo., Dey, Yr.)
<br />AJ)r il 4, 2~g5
<br />
<br />23b. DATE SIGNED (Mo., Doy, Yr]
<br />Apti 5,2005
<br />
<br />Z>-
<br />~~~
<br />a:-a:
<br />]~~
<br />Q,.Q. iI( ~
<br />g~~~
<br />"wZ
<br />1jZ::>
<br />~~8
<br />o~
<br /><)0
<br />
<br />m
<br />
<br />23c. TIM~ OF DEATH
<br />07 :OOa m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis 01 exam;nallon and/or investigatlon,ln my opinion death occurred a\
<br />Iha time, date and pleca and due to the cau,e(.) stetad. (Signature and Tltia) ,.
<br />
<br />23d. TO. th~b7(.Ol m. y. .k.nOWlo.d.g..e, d.e~-.~.o. cc.urred at tho lime, dale end piece
<br />and;!-"lr 0 \Il~ cause(')l'",ed: Ignalure and Tille) ,.
<br />
<br />/. lttl.-~ U./tl . __.-------
<br />
<br />26b. WAS CONSENT GRANTED?
<br />...Not Applicable if 2.~e Is NO 0 YES jl:i'.~O__
<br />
<br />25. DIDTOBAtC SE CONTRIBUTE TO THE D ATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />V,
<br />o YES [J NOn U PROBABLY ~,Y~KNOWN 0 YES_.__ ~ NO __.
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNf;ATTORNEY) (Type cr Print)
<br />John Wagoner M.D. 800 N. Alpha Av., Grand Island. NE
<br />
<br />68803
<br />
<br />
<br />26b. DATE FILED BY REGISTRAR (Mo., Dey, Yr.)
<br />APR -=- 8 2005
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
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