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<br />'!.
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTHAND.HV-'4A~JSERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAfdREC(,!flCtgtv-E!".~ WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAtf$TiCS ~et;,."'QftitWHI,CH IS
<br />
<br />:~::::~:TORY FOR WTAL RECORDS. ~~~ER
<br />
<br />APR 1 7 2006 AsSIS'fANt.tAr~R$ISTjRAR
<br />LINCOLN, NEBRASKA 200603. G t t HEALTH';4.~~N-SER.fJCES
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<br />\
<br />
<br />
<br />L DECEDENT'S.NAME (Flrsl, Middle, Lasl, Sulllx)
<br />
<br />
<br />~ C.ITY AN~'S.TA.TE ORTEA.Be.A. IT::~ I.R.. ~OAEIG=NT.. RY OF B~.. ~1~.A.y~:;~;~.1 BI..rthday.~.~t..~r.~:~. ~R- Fema~ 6. DATE OF BIRTH (Mo" Day, Yr.)
<br />
<br />G~~nd_!sland,_Nebr.as~._ __ . 67 _.I --.1 -.Bo~~ _193-.1_
<br />7. SOCIAL SECURITY NUMBER -- - f6a. PLACE OF bEATH . .
<br />507-42-2661 llilliPl.IA.l Olnpalienl
<br />----
<br />Bb FACILITY. NAME (If nol Inslllullon, give streel and number) 0 ERIOulpalient IZDacedenl's Home
<br />
<br />
<br />..22R NQrth_l3erwick Rood_ __ _ I.:J CO\ OOlher(Specily)_..._.__
<br />Be. CITY OR TOWN OF DEATH (Include Zip Code) -'~OUNTYOFDE~ - -- - ~
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<br />..J'lQod---.River,...6BBB3.._ f--.-- -J9c:CrT - ~all - - ----- --
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<br />~;;:~~ATE ". . . . '.. . 9b~:~ _I gc C';=W~i ver
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<br />~TREETANDNUMBER' - .- -.------. .---- --[ge':'APT NO~16Z8IP8C80D3E- r9uIN.Syl_DEEsCITY,~IMNIToS
<br />228 North Berwick Road _I :J\!
<br />---."--'.'--"..-. ------
<br />lOa. MARITAL STATUS AT TIME OF DEATH (XMerried 0 Nevar Merrled lOb. NAME OF SPOUSE (FlrSI, Middle, Lesl, Suffix) II wile, give melden name.
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<br />STATEOFNEBRASKA-DEPARTMENTOFHEALTHANDHUMANSERVICES'Fm~6~A~DSUPPORT 0 5 02285
<br />---___.~_~.ERTlFLCATE QF DEATlt._____ _______
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<br />~
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<br />2. SEX
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<br />3. DATE OF DEATH (Mo.'-Day, Yr.)
<br />F~uary~ 2005
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<br />50. UNDER 1 DAY
<br />
<br />HOU:[MIN~.
<br />
<br />OllJf!J:
<br />
<br />o Nursing HomellTC 0 Hospice Facilily
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<br />o Married, but separeled q Widowed 0 Dlvorcad U Unknown
<br />
<br />Vernon Harders
<br />11 -FATHER'S.NAME (F~ -----;iddl~ ~t, Sufllx) [;'2 MOTHER'S.NAME-~,-- - M~~ Malden Surna~
<br />Delbert A. Hargens ---.L.. Beulah E. Rauert
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<br />13 EV~RINUS ARMED FORCES? Glved-;te~. O.fserVle-el':yyas 14a IN. FORMANT.NAM. E .' '-'-. '-'" . .l'.b RELATlO.NSHIPTO. 0 ECED'ENT
<br />(Yes, no, or unk ) no Vernon Harders husband
<br />--.--. '- --- jj----' ---.---
<br />15. METHOD OF DISPOSITION 16"'~B~LMER.SIGNATURE () 0 0 16b. LICENSE N~: 16e. DATE (Mo., Day, Yr.)
<br />IXBurlel o Donalion J~v....... VV'\ _~~ J....f 9~.~_ February 25, 200?
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<br />o Cremellon 0 Enlombmenl 16d. CEMETERY, I3)EMATORY OR OTHER LOCATION CITY I TOWN . STAT~
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<br />o Removal 0 Olher (Specify)
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<br />Berwick Cemetery
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<br />Wood River
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<br />-. "'----'----..'._.._-,.~..-
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<br />PART I. Enter the ~;!1_Q.1..~~--disBases, InJuries, or compllcatlonS--lhat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiralory arrasl, Or venlrlcular lib rille lion wllhoul ,howlnglhe atlology. DO NOT ABBREVIATE. Entar only one Cause on a line. Add additional lines II necessary.
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<br />IMMEDIATE CAUSE:
<br />
<br />onsel to dealh
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In dealh)
<br />
<br />(e)
<br />
<br />Cardiac Arrest
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<br />I Immediate
<br />..-.__-----L.::..:.________.
<br />I on'allO death
<br />I
<br />I
<br />
<br />--._-~._----.J._
<br />I onsot 10 dealh
<br />I
<br />I
<br />1_--_-
<br />I on,ello dealh
<br />
<br />- .,-".~'--"-,---_..,'-_.
<br />
<br />DlIF. TO, OR AS A CONSEQUENCE OF:
<br />
<br />SequenU.lly IIsl conditions, It (b)
<br />eny, I"dlng to Ihe caueellsled DUE TO~ OR AS A CONSEOUENCE OF: .--
<br />on linea.
<br />Enlerthe UNDERlYING CAUSE
<br />(dlseasa or Injury Ihallnltlaled (e)
<br />Ihe evenls ,esulllng In daslh)
<br />lAST
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Id)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS.Condltlons conlribullng 10 Ihe dealh but not resulllng in Ihe underlying cause glvan in PART I.
<br />
<br />-l-"-'-"~'
<br />19. WAS MEDICAL EXAMINER
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<br />OR CORONER CONTACTED?
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<br />Xl YES 0 NO
<br />. "~'.._-,-,-
<br />210. WAS AN AUTOPSY PERFORM~D?
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<br />20. IF FEMALE: 21a. MANNER OF DEATH 21b.IFTRANSPORTATION INJURY
<br />XI Nnl pregnenl within pasl year XI Nelural 0 Homicide ODrlvarlOperator
<br />DYES )Q(NO
<br />o Pregnanl 01 lime of.dealh 0 AccldentO Panding Inv.stlgallon 0 Passenger __ _ ___ __ ._
<br />
<br />LJ Nol pregnant, bUI pregnanl within 42 days 01 daalh CJ Suicide CJ Could nol be delermlned 0 PedeSlrlan 21d. WERE AUTOPSY FINDINGS AVAilABLE TO
<br />U Nol pregnant, bul pregnanl43 days 10 1 year belore dealh 0 Olher (Speclly) COMPLETE CAUSE OF DEATH?
<br />U Unknown If pregnanl within Iha past year 0 YES W NO
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<br />220. DATE OF INJURY {Mo, Day,~ 122b TIM~OF INJUR:YLACE OF INJURY.AI home, farm, 'I~eel, leclory office bUilding' con'''oolion Site, el. (SpeCify)
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<br />- 22d INJURYATWORK-i-r 22e DESCRIBE-HOW iNJ'URY OCCURRED - -- -- - -. -- - --. ~
<br />DYES 0 NO
<br />--- - -- - - ~--- ~-- ----- --
<br />22f.LOCATION OF INJURY - STREET& NUMBER, APT. NO. CITYlrOWN STIllE ZIP CODE
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<br />23.. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />.. ..--...".--.-. ._'~._-
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<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />230. TIME OF DEATH
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<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />FebruarLlll..,.2005 .. _.3..:llO...._~
<br />
<br />m
<br />
<br />:0:>
<br />!'~~
<br />;!1Ila:
<br />.'!I>O
<br />uh
<br />~g~~
<br />~z::>
<br />"'00
<br />~a:O
<br />815
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<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />Febru 2
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<br />24d. TIME PRONOUNCED DEAD
<br />am
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<br />~
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<br />23d. To Ihe be,1 of my knowladgn, daalh occurred allhe time, dele and place
<br />and due 10 Iha cause(s) slaled. (Sl9nalure and Tille) T
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<br />
<br />~ot Applloablell 26a Is 1>1.0__ 0 YES 0 NO
<br />Grand Island, NE 68801
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<br />25. DID TOBACCO USE CONTRIBUTnOTHE DEATH?
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<br />DYES 0 NO 0 PROBABLY. XJ UNKNOWN 0 YES .)((;l NO
<br />. 27. NAME~TlTLE AND ADDRESS Oi'CERTlFIER (PHYSiciAN, CORONER'S PHysiCIAN OR'c6UNTYii.TToFiNEY) (Type or Prlnl) -
<br />
<br />2Bb. DATE FiLED BY REGISTRAR (Mo., Day, Yr.)
<br />MAR 3 2005
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