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<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 RRCQfll}-j3NFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/~~~~!t/WjJ.!CH IS
<br />
<br />:::::::~:::::~TORY FOR ;';~R6c~R5s8 71 " ~:~- _~OO~ J:~~,
<br />JAN 11 2006 ~TANLEYSCOOPER
<br />A$.SlJiTANT STATE REGISTRAR
<br />HE'ALTH'~NlJ_HiJMAN StRVICES
<br />
<br />LlNCOLN,NEBRASKA
<br />
<br />I~
<br />
<br />'.:, -:-,,,:~: ':~~, ~ ,:?i:-
<br />
<br />,J
<br />
<br />
<br />_____ STATE O~~_~~~~.~KA - DE:~R~~~;tF~cf;~N~ ~U~~~~~VICES FINANCEANDitfp~~_~tJ~. '_14~ ~.4}~___
<br />
<br />OEC~O~NT'S.NAM~ (First,
<br />Lois
<br />
<br />Middle,
<br />Rachel
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />2,SEX
<br />Female
<br />
<br />3. OATE OF OEATH (Mo" Oay, yr.)
<br />December 31, 2005
<br />
<br />4. CITY ANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Urbach
<br />5a AGe.Last 8~;~~~ay ~~.ER_~Y~~~-
<br />
<br />(Y::,).8.?_ I MO:.J_~A:~
<br />
<br />8a. PLACE OF OeATl1
<br />
<br />50, UNOER 1 OAY
<br />
<br />:~~~~L_MINS
<br />
<br />6, OAT~ OF 81RTH (Mo., Oay, Yr.)
<br />
<br />C!.t-,:lJ~_Ill~n, N e.?r as k(:l___,
<br />7. SOCIAL SECURITY NUMBER
<br />483-14-4352
<br />
<br />July 25, 1919
<br />
<br />1::l.Q.SE1IAJ..:
<br />
<br />~ Inpalienl
<br />
<br />QJ!:!ffi: 0 Nursing Home/LTC 0 Hospice Facility
<br />
<br />8b, FACILITY-NAME (II nol Inslltullon, give atreel and number)
<br />
<br />iJ ERIOulpalienl
<br />
<br />o Decedent's Home
<br />
<br />St. Francis Medical Center
<br />
<br />OM
<br />
<br />o Olher (Specify)
<br />
<br />8c, CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />
<br />8d, COUNTY OF DEATH
<br />Hall
<br />
<br />ga, RESIDENCE-STATE
<br />Nebraska
<br />
<br />9d. STREET ANO NUM8ER
<br />721 South Blaine Street
<br />
<br />9b, COUNTY
<br />Hall
<br />
<br />
<br />gl. ZIP CODE
<br />68803
<br />
<br />gg, INSIDE CITY LIMITS
<br />
<br />Xl YES 0 NO
<br />
<br />lOa. MARITAL STAT"US-'ATT'lME OF DEATH.[X~~;~dD~;~~r Married
<br />
<br />lOb. NAME OF SPOUSE (First, Middle, L.st, Sullix) If wit., give m.iden n.me.
<br />
<br />U Married. bUI separaled 0 Widowed 0 Olvorced 0 Unknown
<br />
<br />Richard Urbach
<br />
<br />11, FATHER'S-NAME (First,
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />SulIlx)
<br />
<br />12, MOTHER'S-NAME (FlrSI,
<br />Emma
<br />
<br />Middle, Maiden Surname)
<br />Fuehrer
<br />
<br />
<br />Otto Rembolt
<br />--13 EVE-RIN U,S, ARMEO FORCES? Give d-a~~ 01 serVice It yes J 1';; INFORMANT~NAM~
<br />(Ye',no,orunk) No Richard Urbach
<br />~~-;o~ OF OISP~;I~ION - -----~6. EMBALMER"SIG~~-A;URE - - - ---~ nl16b LlCENS;~O -
<br />]0 Burlel a Donellon ~~ .'---_Z~_:~tf; _____ _ __ _~/5;lS-
<br />o Crem.tion 0 Entombment 16d, CEMETERY, C ~MATORY OR OTHER LOCATION CITY / TOWN
<br />
<br />14b. RELATIONSHIP TO OECEOENT
<br />Husband
<br />
<br />16c. DArE (Mo., D.y, Yr.)
<br />January 5, 2006
<br />
<br />STATE
<br />
<br />a Removal a Other (Specily)
<br />
<br />Grand Island City Cemetery
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />
<br />17a. FUN~RAL HOME NAME ANO MAILING AOORESS (SlrBel, City orTown, Stale)
<br />
<br />17b. Zip Codo
<br />
<br />68801
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />resplralory arreS!, Or venlrlcular fibrilla lion wllhoulBhowlng the ellology, DO NOT ABBREVIATE, Ente, only one cau.e on e line, Add eddlllonelllnes II necessery,
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condlllon resulllng
<br />In death)
<br />
<br />
<br />(a)
<br />
<br />.r,\. "
<br />\I \.!,L
<br />
<br />\.) \:J--1'-' <<"'-'"'
<br />
<br />c.,U'l'~ (
<br />
<br />I
<br />I
<br />I
<br />
<br />.-\...l'-(f/'","'--.'
<br />
<br />I
<br />I
<br />,
<br />,
<br />
<br />onsello dealh
<br />
<br />I (',,/,Oy'
<br />onsello deell{
<br />\:.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />Sequentially list conditions, if (b)
<br />any, leading 10 Ihe cau.e listed DUE TO ORASA CONSEOUENCE OF'
<br />on line B. I '
<br />Ente, the UNDERLYING CAUSE
<br />(dlsea.e or Injury thallnllleled Ic)
<br />the events resulting In death)
<br />lAST
<br />
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />----.. .........---.---.-
<br />I onsello dealh
<br />I
<br />I
<br />
<br />...____....~___...L...__ .._...
<br />I onsello deelh
<br />I
<br />I
<br />
<br />(d)
<br />
<br />la. PART II OTHER SIG~F\ICANT~~\ONOITIONS'condlllfi~s~~nlributIn9 10 Ihe dealh bul not resulting In Ihe UnrrlYlng cause given In PART I
<br />
<br />,\\J\o..s...is., 6l Q, vv,~ ~,,-.'t''-t.1..... S . flA.-v \...A..-V S \~ _ '-- ~ .
<br />
<br />~FEM;~E ----. --- ----- n_ 2;. JA~~ERClF~~~~ -- 2tb IFTRAN~O~TIONINJURY
<br />~ Nol prBgnanl within past year kalural 0 H~mlclde a Orlver/Operator
<br />
<br />o Pregnanl al limB ot dealh 0 AccldenlU Pending InvesllgBtlon 0 Passenger
<br />U NOI p,egnanl, but pregnanl within 42 days 01 deelh 0 Pedes Irian
<br />o Suicide 0 Could nol be delermined
<br />o Nol pregnanl, bul prBgnanl43 days 10 1 year belore death
<br />
<br />o Unknown II pregnant wllhin the p.st ye.r
<br />
<br />19. WAS MEOICALEXAMINER
<br />
<br />OR CORONER CONTACTEO?
<br />
<br />o YES NO
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />o YES
<br />
<br />J\NO
<br />
<br />a Olher (Speclly)
<br />
<br />21 d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF OEATH?
<br />o YES a NO
<br />
<br />22e, DATE OF INJURY (Mo.. D.y, Yr.)
<br />
<br />22b. TIME OF INJURY 220, PLACE OF INJURY-At home, f.rm, streel, f.ctory. ollice building, conslructlon slle, ele, (Speclly)
<br />m
<br />
<br />"22d iNJURYATWORK7--!22e OESCRiBE HOW INJURY OCCURREO
<br />o YES iJ NO
<br />---- ---- -~----
<br />221, LOCATION OF INJURY - STREET & NUMBER, APT. NO, CITYITOWN
<br />
<br />STATE ZIP COOE
<br />
<br />
<br />23a. OATE OF OE TH (MOl Oay, Yr.) .
<br />
<br />12- ~'I '.)S.~
<br />
<br />23b, DATE SIG 0 (-::;Dey, Yr,)
<br />I IJ "
<br />
<br />24a. OAT~ SIGN EO (Mo., Oay, Yr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />m
<br />
<br />z>-
<br />""'w
<br />~-z
<br />!.!a:
<br />-gUJO
<br />i~~
<br />o.CL II:l ~
<br />E(fj[:z
<br />8f5z0
<br />~Z::l
<br />''''08
<br />{la:
<br />81;
<br />
<br />m
<br />
<br />23c, TIME OF DEATH
<br />2./,':J--('
<br />
<br />240, PRONOUNCEO OEAO (Mo" O.y, Yr,) 24d. TIME PRONOUNCEO OEAO
<br />m
<br />
<br />23d. To the b slof knowledge, death occurred al the time, date and place
<br />e(tledr-( .. IttTundlltto)., '-.' -
<br />~J ""\" iU tf\
<br />'J c.J., \I - "IJ.)
<br />
<br />24B. On the basis of examination and/or investIgation, in my opInion death occurred al
<br />Ihe \tIne, date ani.! :Place MnQ d\'o.g...:~ the C<i.us$) s:atfld.-{Slgno:;t1,ua..ac.d....IJ.1}Q..f..l'~ _
<br />
<br />25, DID TOBACCO USE CONTRI8UTETOTHE DEATH? 26., HAS ORGAN OR TiSSUE DONATION BEEN CONSIDERED?
<br />
<br />o YES ~NO 0 PROBABLY 0 UNKNOWN 0 YES !r'NO
<br />"27, NAME, i'ifiDND ADDii~SOF CERTII'I~ii . (PHYSiCIAN, CORONER'S PHYSICIAN i5R-~\TTORNEY) (Type or Prlnl)
<br />
<br />Dr.William J. Landis
<br />
<br />28b, WAS CONSENT GRANTED?
<br />
<br />Not Applic.blel128e I. NO 0 YES 0 NO
<br />
<br />28., REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b, DATE FILEO BY REGISTRAR (Mo" Oey, Yr,)
<br />
<br />~\(
<br />
<br />JAN
<br />
<br />9 2006
<br />
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