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<br />......,. <br /> <br />...:' <br /> <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 />