|
<br />
<br />.\
<br />
<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 ORIGINAt!-RECo,:,I10NFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST41fST/CS S~ili:JN;WI'!!CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS c""f .".....~.. ". '.. ';:' ..". -,,"c.,
<br />
<br />. ......-.....4....~...........
<br />~... .
<br />- - . ... . .-
<br />."".. .. - -
<br />. _. n._
<br />.::- ~~.. ". '. ".. '-:.':'
<br />. _ "". ..L' .:.;.., .'~':
<br />;. " .~.TANiJE~B. (;Od~ER
<br />ASSISlANT STATE REGISTRAR
<br />HEA;L TH:AND:cI;ll)I)AJtt' SERVicES
<br />
<br />DATE OF ISSUANCE
<br />
<br />MAY 0 2 2006
<br />L!NCOLN, NEBRASKA
<br />
<br />200607690
<br />
<br />... ._~~AT~_OF NEBRASKA~ DEPAR~~;;r ~~~;~.~~ ~U~~N~,:~VICES FI.NANCE AND~U:PORO 6 2 4 {. 4 5
<br />
<br />"
<br />
<br />
<br />I. DECEDENT'S.NAME (First,
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />2.SEX
<br />
<br />3, DATE OF DEATH (Mo., Day, Yr,)
<br />
<br />A ril.27. 20Q6
<br />6. DATE OF BIRTH (Mo., Day, Yr,)
<br />
<br />",Male
<br />
<br />__.Daniel .....___.A. Ewoldt
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE.LaS! Birthday 5b. UNDER 1 YEAR 5c, UNDER 1 DAY
<br />(Yrs,) ~ ['-DAYS HOURS MINS
<br />
<br />Hall County. Nebraska 88 ~2
<br />
<br />J ::~,;,~~
<br />I::I.Q.Sfl1AL 0 Inpallent
<br />o ER/Outpallanl
<br />
<br />0000\
<br />
<br />.July 25_,
<br />
<br />1917
<br />
<br />508-14:-3026._
<br />
<br />QJl:lEB:
<br />
<br />o Nursing Home/LTC 0 Hospice Facillly
<br />
<br />FACILlTY.NAME (II not Inslllullon, give streel and number)
<br />
<br />[JCDecedent's Home
<br />
<br />312 East 19th
<br />
<br />I:) Other (Speclty)
<br />
<br />8c, CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />Bd, COUNTY OF DEATH
<br />
<br />_.~~11AJsland_,
<br />9a, RESIDENCE.STATE
<br />
<br />Hall
<br />
<br />"'=r'" ",.. .
<br />9c. CITY OR TOWN
<br />Grand Island
<br />.---.. .... 1~~'-APUiOI91. ~P;;~E 1 ~9g~S~~: CITY~Mt~~
<br />
<br />. .-.."'..-'--.- .".,
<br />lOb. NAME OF SPOUSE (first, Middle, Lasl, Suffix) If wife, 9ive maiden name.
<br />
<br />9b, COUNTY
<br />
<br />. _ Nel?!"ask~_.
<br />9d. STREET AND NUMBER
<br />
<br />Hall
<br />
<br />__.312 Ea.E!t 19th._
<br />10., MARITAL STATUS ATTIME OF DEATH 0 Married 0 Never Married
<br />
<br />o Married, but s.parated IllI Widowed 0 Divorced 0 Unknown
<br />
<br />Evelyn Danburg
<br />
<br />11. FA'fHER'S'NAM'~-- Middle, Last, Suffix) ..--~HER'S.NAME (Flrs~-
<br />Herman Ewoldt~. Matilda
<br />----;;:-. EVER IN U:-s ARMED..FORCES? Give. d...a.les ~f~ervlce II ye. .s. '..l'14a: INFORMA..N.. T'.NAME . --
<br />(Yes, no, or unk,) No Dan Ewold t
<br />~,ME~~OD OF DISPOSITION ,m NA~URE-/r-=:/l'-.. 116b. LICENSE. .NO'
<br />m Burial ODonallon L!2!! (0!:~ I... L 1191 ___
<br />o Cremation 0 Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN
<br />
<br />Middle, Melden Surname)
<br />Krueger
<br />
<br />t4b. RELATiONSHIP TO DECEDENT
<br />
<br />Son
<br />
<br />16c, DATE (Mo., Day, Yr, )
<br />May 3, 2006
<br />
<br />STATE
<br />
<br />o Removel 0 Other (Specify)
<br />
<br />Westlawn Memorial Park
<br />
<br />Garnd Island
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreet, City orTown, Stale)
<br />Livingston-Sondermann Funeral Home, 601 N.
<br />
<br />"-lIB. PART I. Enter the ~t~ndlseases, injuries, or complicallons--Ihal dlreclly caused the death. DO NOT enter terminal events such as cardIac arrest!
<br />f - respiralory arresl, or vantricular IIbrillatlon without showing the etiology, DO NOT ABBREVIATE. Enter only one cause on allne, Add addlllonalllnes il necessery,
<br />V IMMEDIATE CAUSE:
<br />1" C)
<br />(a) ~12...
<br />.n_ ,
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I
<br />II-
<br />
<br />I onset 10 death
<br />I
<br />I
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resultIng
<br />In daath)
<br />
<br />:J ;€
<br />J . jl.--':';;X-c-.fJ
<br />
<br />on:Jto:~:'J>-<:?
<br />
<br />I
<br />I
<br />_J_..__
<br />1 onset to death
<br />I
<br />I
<br />
<br />.L--._. ._"
<br />I onsello death
<br />I
<br />I
<br />
<br />r WAS MEDic'AL EXAMINER--
<br />
<br />OR CORONER CONTACTED'
<br />
<br />U Y!;S ~O
<br />
<br />sequentially lIat condition., II (b)
<br />any, teadlng to the cau.ellsted - DuiTo, OR AS A CONi;iQUENCE OF: ,...
<br />onlln!'8.
<br />Enter the UNDERLYING CAUSE
<br />(dls..se or Injury that Inltlsted (c)
<br />the e.entsresultlng In death)
<br />lft,Sl'
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(d)
<br />
<br />1B, PART II. OTHER SIGNIFICANT CONDiTIONS.Conditlons contributing 10 the death bUI not resulting In the underlying cause given In PART I.
<br />
<br />20. IF FEMALE:
<br />
<br />~a, MANNER OF DEATH
<br />f ~atural 0 Homicide
<br />
<br />~b.IFTRANSPORTATION INJURY
<br />I' U Driver/Operator
<br />
<br />o P....nger
<br />
<br />U Pedeslrlan
<br />
<br />o Other (Speclly)
<br />
<br />c, WAS AN AUTOPSY PERFORMED?
<br />
<br />o YES
<br />
<br />J3:.,N 0
<br />
<br />o Not pregnarH within past year
<br />o pr.gnant at lime of death
<br />o NOI pregnanl, but pregnant within 42 deys of d.ath
<br />o Not pregnant. but pregnant 43 days to 1 year before death
<br />o Unknown if pregnant within the past year
<br />22a DATE OF INJURY (Mo, Day, Y~b TIME OF INJUR:
<br />
<br />m INJURY ATWO.RK? -\ 22_e. DESCRiBE. HOW INJURY OCCURRED
<br />o YES 0 NO
<br />22f. LOCATION OF INJURY, STREET & NUMBER, APT. NO.
<br />
<br />I:) AccidentO Pending Investlgallon
<br />
<br />o Suicide 0 Couid not be determined
<br />
<br />'f' WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES 0 NO
<br />
<br />22c. PLACE OF INJURY.At home, larm, streel, factory, office bUilding, construction site, elc (Speclly)
<br />
<br />CITYIfOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo" Day, Yr.)
<br />
<br />24a. DATE SIGNED (Mo" Day, Yr,)
<br />
<br />24b, TIME OF DEATH
<br />
<br />1i~~
<br />]iii'"
<br />t>O
<br />'E.i!:~~
<br />e"'" i: ~
<br />ttffiz
<br />.8Z::O
<br />t2~8
<br />815
<br />
<br />m
<br />
<br />Z
<br />~~
<br />Ill.!
<br />"g!
<br />c.7:~
<br />E a. Z
<br />5 "'0
<br />u c
<br />.8~
<br />o ~
<br />I- .1'
<br />..
<br />
<br />
<br />_Aoril__ZL......1QQ6 .-
<br />m, DATE SIGN D (MO'!,D ,Yr.) 23c. TIME OF DEATH
<br />r t....'),..1j O~ 8:50 Am
<br />
<br />:1&1, To Iho be t of my.. knowledge, death occurred at the time, dale .nd place
<br />f' and due 10 th~~.aus..e. (s~ ted, (.S..lgnature and Title. ) T
<br />
<br />/ " /~ (1/\ ()
<br />
<br />t. DID TOBACCO USE CONTRI 'f-a, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />... 0 ~.~~...,..~... 0 PROBAB~Y. 1..1 UNKNOWN ~_:>'~_.. ~._._,
<br />~ME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ. or Print)
<br />Dr. G.J. Hrnicek, 729 N. Custer, Grand Island, NE 68803
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />1 2006
<br />
<br />240, PRONOUNCED DEAD (Mo" Dey, Yr.)
<br />
<br />24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of examination and/or invElsligaHon, in my opInion death occurred at
<br />the time, dale and place and due to Ihe cause(s) .Iated. (Slgnatur. and Tille) T
<br />
<br />2j(.WAS CONSENT GRANTED?
<br />No.I.Appllcable H~6e Ie NO O,XES ...QK'fi()
<br />
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />MAY
<br />
|