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<br />,. DECEDENT - NAMe <br /> <br />,"- <br />WHEN THIS copy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA TISTlCS SEC'[_~Wfij(jkt$" <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . ~. tP.>l:~.tr.~ ~'=-.~"'.; '~.'.-~;.~:~:.:.-.'-.':=O <br /> <br />DA TE OF ISSUANCE . K/..-'~. "-5.'.0 <br />2 0 0 6 0 614 5 . 'ANtEY S.COOPER ~. -o~ <br />7/14/2004 ASSISTANf:Si'ATElRelJI&'lIMR, ":1 L~ <br />LINCOLN, NEBRASKA HEAL TH AND HUMA~Sf!J~Vfbi~'f~o;j~; <br />STAlE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES PiNANCE ~ai -:,~c.," <br />VITAL STATISTICS C - '-='",: - -" :iT! ~ jJ -;. 0 7 4 8 4 <br />CERTIFICATE OF DEATH - - 0-" --- --~ /:U 9' - , <br />_.". I. :.':""- <br /> <br />-- ~ST- '_.~ SeX ~=--lJ.DATeof~~~~:~2~~ ;~~4 <br /> <br />UNDER 1 VEAR UNDeR 1 DAV 6.-DATE'OF"BiRTl-f/Monlh. Day. Y.a,) <br />MOS. DAYS 50. HOURS' MINS. <br /> <br />FIRST <br /> <br />MID OLE <br /> <br />James Lee Roy Rieken <br />-.{. CITY AND STATE OF BIATH--iiinoiin-US:;'C nom. country) 50. AGE - Lao. Slrthdoy <br />{Y".I <br /> <br />Longpine. Nebraska <br /> <br />64 <br /> <br /> <br />July 21, 1939 <br /> <br />7. SOCIAL SECURTIY NUMSeR <br /> <br />209 Spruce Street <br /> <br />80. PLACE OF DEATH <br />~~~liAL; D Inp:atient <br />D ER Outpati.nl <br />D DOA <br /> <br />~; D NlJ(sln~ Home <br /> <br />[Xl Flesldence <br /> <br />D Otl1er IS~t;H;Jfvl <br /> <br />505-48-5407 <br /> <br />Bb. F= ACIUTY - Name (If tlof if/Sf/lUlian, givtJ str861 and number) <br /> <br />Howard <br /> <br /> <br />8d. INSIDE CITY LIMITS <br /> <br />8c. CITY. TOWN OR LOCATION OF DEATH <br /> <br />9.. RESIDENCE. STATE <br /> <br /> <br />St. LiborY <br />COUNTY <br /> <br />Howard <br /> <br />9d. STREET AND NUMBER (Including Zip C_I 90. INSIDE CITY LIMITS <br /> <br />Nebraska <br /> <br />68872 VO' D No [!] <br /> <br />10. <br /> <br />O.c.IISPOCitvlAmerican Indian <br /> <br />11. ANCESTRV 1..9-- <br />ISpec,fy) <br /> <br />NAME OF SPOUSE {If WIfe. give maldM namaJ <br /> <br />American Indian <br /> <br />Susan Mommens <br /> <br />14a. USUAL OCCUPATION (Give kind of work dontl during most <br />of working IifB. 8118n if fBUrsdJ <br /> <br />16. FATHER.. NAME <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />~ST <br /> <br />Manufacturing <br />17. MOTHER <br /> <br />College 11.4 or 5"\ <br /> <br />Foreman <br /> <br />1 B. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />{YElS. no, Or unk.l I (II YB!;;. gM!I war and dales of S8rvic8S) <br />Yes KDrean War <br />19b. INFORMANT - . -.---..-MAILINGADDRESS ..--. <br /> <br />4/12/57 <br />4/11/61 <br />ISTREET DR R.FD. NO.. CITY OR TOWN. STATE. liP) <br /> <br /> <br />MAIDEN SURNAME <br /> <br />Carl Rieken <br /> <br />Sarapphine Herschel <br /> <br />Susan Rieken <br /> <br />209 Spruce Street St. Libory, Nebraska 68872 <br /> <br />21.. METHOD OF DISPOSITION 21 b. DATE <br /> <br /> <br />21c. CEMETERY OR CREMATORY NAME <br /> <br />1240 <br /> <br />G Burial 0 Removal <br /> <br />Jul 3, 2004 <br /> <br />Westlawn Memorial Park <br /> <br />22a. <br /> <br />21d. CEMETERY OR CREMATORY LOCATION <br /> <br />CITY OR TOWN <br /> <br />STATE <br /> <br />D Cremation D DonatiOI'! <br /> <br />Grand Island, Nebraska 68803 <br /> <br />22b. FUNERAL HOME ADDRESS <br /> <br />ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) <br /> <br />1123 W. 2nd St. Grand Island, Nebraska 68801 <br /> <br />23. IMMEDIATE CAUSE ~ <br />PART - 1 , <br />___~i!'1 ____ S' t'4i ~ ' e <br />DUE TO. OR AS A CONSEOUENCE OF' <br /> <br />{ENTER ONLY ONE CAUSE PER LINE FOR 1.1.lbl. AND (ell <br /> <br />tA tv> I d..h- Y of'-+n1 / <br /> <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br /> <br />.;J YA J <br />Interval b8tween onset and deal!1 <br /> <br />Interval belween onset aM destl1 <br /> <br />101 <br />DUE TO. DR AS A CONSEOUENCE OF <br /> <br />h,terval between onset and de<.ilh <br /> <br />(el <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related <br /> <br />P~n vv I>rt.. f 4 J l..A..VL[ I) \ t.1 ~ l fL S <br /> <br />2Gb. DATE OF INJURY I . Oay. Y'L 26C. HOUR OF INJURY <br /> <br />Homicide <br /> <br />Investigation <br /> <br />26.. INJURY AT WORK <br />Y.. D No D <br /> <br /> <br />269. LOCATION <br /> <br />STREET OR R.FD. NO. <br /> <br />C:::: <br />.o;i OR TOWN STATE <br /> <br />I ~B. <br />'0 <br />)0 <br />o <br /> <br />Aceldenl 0 Undetermined <br />Suicide 0 Pending <br /> <br />280. PRONOUNCED DEAD {Mo.. Doy. Y'.I <br /> <br /> <br />C> <br /> <br />if.. 'DATE OF DEATH IMO__ Day. Y'I <br /> <br />28.. DATE SIGNED {Mo.. Oay. Y',I <br /> <br />2Bb. <br /> <br />: 29. <br /> <br /> <br />$~ <br />:!1ii\ <br />~'i:'j <br />8~8 <br />Mi <br />o ~ <br />~-11 <br /> <br />June 29,2004 <br /> <br />s~i <br />1"'0 <br />~t::>- <br />~~~ <br />M~'S <br />o 0 <br />~ u <br />u ~ <br /> <br />M <br /> <br />(HOUll <br /> <br />M <br /> <br />M <br /> <br />288. On the basis of eltamination andlOf investigation, in my opinion death occurred at <br />the time, date and place arid due to the' cause(sl stated. <br /> <br />NO <br /> <br />30.b WAS CONSENT GRANTED? <br />DYES <br /> <br />;gJ NO <br /> <br />32.. REGISTRAR <br /> <br />ITYfJIl(}r 'on <br />Grand Island, Nebraska. 68803 <br /> <br />321>. DATE FILeD BY REGJOl 11 o~ Y,Z004 <br />