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<br />Lot Three (3), in Block Twenty-Seven (27), in Charles Wasmer's Addition
<br />to the City of Grand Island, Hall County, Nebraska.
<br />
<br />, .
<br />
<br />WHEN THIS copy CARRIES THE RAISED SEAL OF THE NEBRASKA HEA~N SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE O~~.FILE WITH
<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VlTAL6A ii:iircs.3SC1iIJ1iJwHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. it.".;~\ #.-t}'~O~ '$.~'YJr
<br />
<br />DATE OF ISSUANCE 20060'7515 ~!{;: ,..--: ==- . ~. "':." ~i '$Av
<br />MAR 11 1999 eo: ::::, ,.~ = - ,&':C'DOPER
<br />~~/STANT STA TlI/tiEtiisTRAR
<br />UNCOLN, NEBRASKA HEALT#~NWtJIJMAfl.$M)lfCE!(![jYSTEM
<br />STATE OF NEBRASKA. DEPARlMENTOF REALm AND ~EtVi~AN~iOOl SUPPORT
<br />VITALSTAnSllCS"fu'....,... '-- , ~S-'" ~
<br />,....;..:... . ~==:;.: ... ~
<br />CERTIFICATE OF DE~'-"-~"":"7"
<br />,. DECEDENT. NAME FIRST MIDDLE LAST 2. ~~X 3. DATE OF DEATH IMonth D.y. y.."
<br />
<br />. Loomis, Nebraska
<br />: 1. SOCIAL SECURTIY NUMBER
<br />I
<br />1 507-12-1038
<br />J lb. FACILITY. N_me (N not ''1'_ give.".., """ numIwI
<br />
<br />~ St. Francis Medical Center
<br />Be. CITY. TOWN OR LOcATION OF DEATH
<br />""l1rand- :t~Tancf, Nebraska
<br />
<br />Clarence
<br />.. CITY AND STATE OF BIRTH /Nnotin USA n,""(lcountryl
<br />
<br />
<br />9a RESIDENCE. STATE
<br />
<br />Nebraska
<br />
<br />Louis Karsten
<br />50, AGE. Lost BIMday UNDER 1 YEAR
<br />IY...I 5b. MOS DAYS
<br />76
<br />
<br />
<br />July 8, 1922
<br />
<br />March 4, 1999
<br />6, DATE OF BIRTH lMonItI, Day. Yo.,/
<br />
<br />sa, PLACE OF DEATH
<br />
<br />D Nursing Home
<br />D RB.iOonce
<br />D OIl>8r (Speedy'
<br />
<br />HOS.~ITAL
<br />
<br />llil
<br />D
<br />D
<br />
<br />OOA
<br />
<br />Inpa1ient
<br />
<br />OTHER:
<br />
<br />ER Outpatitnt
<br />
<br />
<br />ad, IN&lllE ClJ'>.lolWl. ~
<br />
<br />9d. STREET AND NUMBER (InchJ<1ing;Zip C_,
<br />
<br />ge INSIDE CITY LIMITS
<br />
<br />etcllSPBCilyt~i te
<br />
<br />11, ANCESTRY lo,g" ltt/Wl.lAt.ictn. Gtnntn, Olel 2.0
<br />ISpeclly1 American
<br />
<br />Ya. I!J No 0
<br />13. NAME OF SPOUSE (Nw;iB. iJ'VB"",iclBn 'I'''''''
<br />
<br />"a. USUALOCCUPATION IG'VBkindOl_~dIH/ng""""31q
<br />,1 01 _.-.gille, -- ""~"""
<br />~ Railroad Clerk
<br />~i 16. FATHER. NAME FIRST MIDDLE
<br />
<br />1 Louis Fredrick Emma
<br />.... 18. WAS DECEASED EVER IN us. ARMED FORCES?
<br />(Yes. no. or unk.l Ilf ye&. give war al'Wj dares of servlctls)
<br />Yes WWII 10-16-42 10-13-45 Grace G. Karsten
<br />19b. INFORMANT MAILING ADDRESS ISTREET OR R:F,D, NO.. CITY OR TOWN, STATE. ZIPI
<br />
<br />
<br />Apfel-Butler-Geddes
<br />
<br />Pauline
<br />
<br />Haeffner
<br />
<br />Island Nebraska 68801
<br />9.J r 210, METHOOOFDISPOSITION 21b, DATE
<br />
<br />IX] Burial D Ramoval
<br />
<br />
<br />21 c C<METERY OR CREMATORY NAME
<br />
<br />STATE
<br />
<br />(STREET OR R.F.D. NO" CITY OR TOWN, STATE. ZIP)
<br />
<br />Dc""';" D Donal"" Kearney, Nebraska
<br />
<br />
<br />22b FUNERAL HOME ADDRESS
<br />
<br />26b. DATE OF INJURY (Mo" Oily. Y'I ;!Go HOUR OF INJURY
<br />
<br />
<br />26a
<br />0 AC!:;I08nt 0 Undetermined
<br />0 SUIcide 0 Pending
<br />0 Homicide Invesllgation
<br />
<br />2tie. INJURY AT WORK
<br />y.,O NoD
<br />27a. DATE OF DEATH (Mo..Ooy Y',J
<br />
<br />"lr~
<br />.~ I~ >-
<br />.. l~
<br />: "f
<br />.. :!
<br />.
<br />)
<br />
<br />March
<br />27b. DATE SIGNED
<br />
<br />4
<br />
<br />3-4-99
<br />
<br />27~ ~~~~:I~=_~~my knowledge. ~e.th L::lj li..ma, ~
<br />
<br />lSI nature and Title lit-
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />YE D NO D UNKNOWN
<br />
<br />26g. LOCATION
<br />
<br />STREET OR R.F.D. NO.
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />26_ DATE SIGNED IMo. Day Y'I
<br />
<br />21lb TIME OF DEATH
<br />
<br />M
<br />
<br />21c. TIME OF DEATH
<br />
<br />26< PRONOUNCED DEAD IMO Dsy, YO
<br />
<br />28d. PRONOUNCED DEAD (Hou,(
<br />
<br />M
<br />
<br />28f1. On the basis of examination anel'or investigation. In my opinion dfl81h occurred at
<br />1M lime, elate and place a.na dUB to tile cause(s) stated.
<br />
<br />30.b WAS CONSENT GRANTED?
<br />DYES DNO
<br />
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY\ (TYPB '" P"nll
<br />
<br />Island I Nebraska 68803
<br />32b. DATE FILED BY REGISTRAR (Mo., Oily yo
<br />
<br />
<br />Dr. William J.
<br />32_. REGISTRAR
<br />
<br />MAR 1 0 1999
<br />
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