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<br />STATE OF NEBRASKA
<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 RECORp qNFILEWITH
<br />i THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSr~f?-~;J!!fffrr9.~~~';H ~t?
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~-~~ ~.;.'-tJ~-~.
<br />
<br />DATE OF ISSUANCE n -,.. KJ. ~ __ o~':
<br />::0 :~, .- . TANLEY 5. CQSP6R
<br />MAR 0 6 2006 200603568 ASSISt!'N"tiSrATEREGI$TRAyI
<br />LINCOLN, NEBRASKA HE~L rl{--~ND_ HUMAN SE,llfltCJ;S
<br />-.-' '~
<br />
<br />
<br />.... __" _ m _cc~#'?"
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 'F{NANCEAND SUPPORT
<br />_ CERTIFICATE OF DEATH -.-..:-:c--:-06 21662
<br />1. DECEDENT'S.NAME (First. Middle, Lssl, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />Kenneth Layton Geiken Male February 16, 2006
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Gothenburg, Nebraska
<br />
<br />5a. AGE-Lest Birthday 5b. UNDER 1 YEAR
<br />
<br />(Yrs.) 82 MOS. DAYS
<br />
<br />50. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />a. DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />October 5, 1923
<br />
<br />7. SOCIAL SECURITY NUMBF.R
<br />507-18-7582
<br />
<br />8a. PLACE OF DEATH
<br />JiQSP1IAl.: Xl Inpalient
<br />
<br />QlliER U Nursing Home/LTC D Hospice Facility
<br />
<br />FACILITY-NAME (If not insllfution, give slreel and number)
<br />
<br />r:l EPmlltr.::'.\i~t")\
<br />
<br />o O:::;c~:!::!~~',;: I--!~T.::
<br />
<br />St. Francis Medical Center
<br />
<br />D lXl'\ I..J Othar (Specityl...
<br />
<br />---red. COUNTY OF DEATH
<br />Hall
<br />
<br />'l"~-'- '---'
<br />. 9.0.. . CITY OR TOWN
<br />Grand Island
<br />
<br />
<br />"'---~g" APT NO f~~E02
<br />
<br />lOb. NAME OF SPOUSE (First, Mlddla, Last, Sulllx) II wife, give maiden name.
<br />
<br />9g. INSIDE CITY LIMITS
<br />Xi YES D NO
<br />
<br />~
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />il;z~i Grand Island . _~6~803
<br />a!i~' 9a.RESIDENCE.STATI: ~-~
<br />~i{ _.___~ebraska______~~ll
<br />
<br />;f,j.~ 9d.ST;~;A~DN~~BE;ismark, P.O. Box 402
<br />
<br />;,i~.i.:.i lOa. MARITAL STATU-S Ai- i-i;;;E'OF'DE'ATH ~ Married D Never Marrlad
<br />
<br />,~: U Married, bUI separated D Widowed U Divorced D Unknown
<br />~B:l,j---
<br />)~~:: 11. FATHI:R'S-NAME (First, Middle, Lasl, Sufllx)
<br />r~ Harry Geiken
<br />j;l~:; 13 EVER IN U.S. ARMED FORCES? Give dales of service 114"S 14a INFORMANT-NAME
<br />,;"~h_J~s,no.~r~nkIYes: WI_I _liM{bZ~ Dolores
<br />:;;;,;,~ 15 METHOD OF DISPOSITION 16a EMBALMER.SIGNATURE
<br />,~~ CXeurial [lDonatlon_ .~~~
<br />I ~:::: ~::::;;"" "'::::: '~':::::~::::':;
<br />~~\,X
<br />'~..~'
<br />i~~!i~
<br />
<br />Dolores Brush
<br />
<br />12. MOTHER'S.NAME (First, Middle,
<br />Elizabeth M.
<br />
<br />Malden Surname)
<br />Koster
<br />
<br />Geiken
<br />C' LICENSE NO:.p-;? z 5'
<br />
<br />.. .,--- ,.-...',--
<br />CITY / TOWN
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />16e. DATE (Mo., Day, Yr.)
<br />Februarr 20, 2006
<br />
<br />STATE
<br />
<br />Grand Island, Nebraska
<br />
<br />
<br />
<br />
<br />17b. Zip Code
<br />68801
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Streat, City or Town, Stalel
<br />
<br />Apfel Funeral Home, 1123 West Second,
<br />
<br />PART I. Enter the chain of evenls..diseases, Injuries, or complicationsnthet directly caused the death. DO NOT enter terminal events such as ca.rdlac arresl,
<br />respiratory arresl, or venlrieular librlllellon without showing the etiology. DO NOT ABBREVIATE. Enler only one cause on a line. Add additional lines II necessary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDtATE CAUSE (Final
<br />disease or condition resulting
<br />In death)
<br />
<br />IMMEDlAT~ CAUSE:
<br />
<br />--.:s) "U:1~kV\5k",'\_Lliy()5nQ~<:;'('c1')
<br />DUETO, OR A A CONSI:OUENCE OF: r- \~
<br />
<br />onset to death
<br />
<br />~
<br />
<br />
<br />I onset 10 death
<br />I
<br />
<br />Sequenllallyllstcondltlons,lf (b) G h _61~c\ :
<br />eny,leadingtothecousellsted DUE TO, OR AS A CONSI:QUENCE OF: I Onsello death
<br />on linea. J~; ('"' I
<br />Enter the UNOI:RLYING CAUSE -- . I'l r: 1ft I
<br />
<br />(tdhleeasetOsrr.ln.luulrytlnlgh,anldlnelallt"htjed (c) ________:...._.. _1:'..'" II.. I
<br />:;v.n DUE TO, OR AS A CONSEQUENCE OF: r-t " "fill) --.. -- I onsello death
<br />
<br />
<br />
<br />16 PART I;OTH~R SIGNIFICAN~d~ONDITIONs-condltlons contnbutmg to Ihe death but not resulting m the U;de-;IYln9 ea~se given In?~t>.~ 19 :WM MI:DICAL ExAMINER
<br />OR CORONER CONTACTED?
<br />
<br />U YES lJ NO
<br />- -
<br />20. IF FEMALE: 21a. MANNER OF DEATH 21b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />D g'Natural D Homicide D Driver/Operator
<br />Not pregnant within past year,.. DYES
<br />o Pregnant al time of death 0 AccidentO Pending Investlgatlon 0 Passenger
<br />[l Not pregnant, bUI pregnanl wilhin 42 days 01 death D Suicide D Could nol be determined D Pedestrian 21d. WERE AUTOPSY FINDINGS AVt>.ILABLE TO
<br />D Not pregnant, but pregnant 43 days to 1 year befora dealh U Other (Specify) COMPLETE CAUSE OF DEATH?
<br />D Unknown if pregnanl within the past year DYES -.l! NO
<br />22~~_:_~U~!~~_'~,~}..-.:~ :2_~ T~~OF 1~5J}}~~~~F.J.ti~U~~~firC." ~!~~lrlf.iJ,lIU~iQil~r,Q "~_.~_:l;~)"'.
<br />
<br />
<br />22d.INJURY AT WORK? 22". DESCRIBE HOW INJURY OCCURRED
<br />
<br />~~O
<br />
<br />D ~ES__~O
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STArE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />FEBRUARY 1~~__2006
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />A. m
<br />
<br />Z)-
<br />~~!l!
<br />lli/jO:
<br />.9!~~
<br />Q. a.. tC( ::i
<br />E _"')- Z
<br />8ffi!;;;0
<br />~Z"
<br />"'00
<br />~o:u
<br />o ~
<br />U 0
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIMI: PRONOUNCED DEAD
<br />m
<br />
<br />248. On the basis of examination and/or Investigation, in my opinion dealh occurred at
<br />Ihe lime, dale and place and due to the eause(s) stated. (Signature and Title IT
<br />
<br />25. DID TOBACCO USE COI'ITRIBUTETOTHE DEt>.TH? 26a. HAS ORGAN OR TISSUI: DONATION BEEN CONSIDERED?
<br />
<br />~ .
<br />lJ YES D NoD PROBABLY UNKNOWN DYES . NO
<br />27, NAME, TiTLE ANDADORESS OF CERTIFIE (PHySICiAN: CORONER'S PHYSICIAN OR COUN~TOiiNEY)'(Type ofP-,lni)-'
<br />Douglas J. Herbek M.D. 2444 W.Faidley Ave., Grand
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />Not Applicable II 26a Is NO U YES D NO
<br />
<br />28a. REGISTRAR'S SIGNt>.TURE
<br />
<br />
<br />Island, NE. 68803
<br />28b. DATE FILFEErrr toO~y, Yr.1
<br />
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