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<br />STATE OF NEBRASKA
<br />
<br />\,~"...
<br />.""
<br />
<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 RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC~.SFCT:ltJNi:-WHICH IS
<br />
<br />:~:::::~:E~RY FOR VITAL RECORDS. ~tf~~
<br />APR 1 0 200n 2 0 0 6 0 7 7 5 3 AS$JSTANTF$JA7~'tJBj;!StiiMj,
<br />LINCOLN, NEBRASKA HEA4.THAND HUMAN SEfrVlqESj
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICEsFl~ANC!;AflJ. .D. su.p~._._..~ 6' .2_ .',.3. ) 6,1-, .__1__'
<br />CERTIFICATE OF DEATH - ,~~::c.~e_ JJ~__.
<br />I. DECEDENT'S-NAME (Firsl, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />
<br />4. CITY AND 'STATE OR T.RRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a. AGE-Last Birthday
<br />(Y".)
<br />
<br />
<br />nMarch17,2006---
<br />6. DAT. OF BIRTH (Mo" Day, Yr.)
<br />
<br />Ashton, Nebraska
<br />
<br />75
<br />
<br />October 7, 1930
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />505-36-3979
<br />
<br />8a. PLACE OF DEATH
<br />
<br />tlUmL
<br />
<br />o Inpatlant
<br />
<br />QlliEB: 0 Nursing Home/LTC 0 Hospice Facility
<br />
<br />eb. FACILlTY.NAME (If not irrstitution. ()lvEI street and numbiH)
<br />
<br />o ER/Oulpali."t
<br />
<br />a Dacade"I's Home
<br />
<br />" \
<br />
<br />
<br />................
<br />
<br />1320 Lilley Street
<br />
<br />UroI
<br />
<br />o Olher (Specify)
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Coda)
<br />
<br />Wood River
<br />9a. RESIDENCE-STATE
<br />
<br />Nebraska
<br />
<br />9d. STREET AND NUMBER
<br />
<br />8d. COUNTY OF DEATH
<br />
<br />Hall
<br />
<br />
<br />Hall
<br />
<br />9b. COUNTY
<br />
<br />Wood River
<br />81.ZIP CODE
<br />
<br />9g, INSIDE CITY LIMITS
<br />YES 0 NO
<br />
<br />n~__1320_ Lllley_StreeL
<br />lOa. MARITAL STATUS ATTIME OF DEATH iI Married 0 Never Married
<br />
<br />68883
<br />Wb. NAME OF SPOUSE (First, Middle, Lasl, Sulllx) If wlfa, give maiden name.
<br />
<br />o Marrlad, bUI saparalad 0 Widowed U Dlvorcad U Unknown
<br />
<br />Joyce Koehler
<br />
<br />11. FATHER'S-NAME (First,
<br />
<br />Middle,
<br />
<br />Last.
<br />
<br />Sullix)
<br />
<br />12. MOTHER'S-NAME (First,
<br />
<br />Mlddla,
<br />
<br />Maiden Surname)
<br />
<br />Peter lS!2l1kowtil5ln
<br />13. EVER IN U.S. ARMED FORCES? Give dalas of service If yes. 14a.INFORMANT-NAME
<br />
<br />(Yas, no, or unk.) Yes .D.e
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />U Cremallon U Enlombmenl
<br />
<br />
<br />K EJf
<br />ro18b. L1C~N~E NO;,./3'z.r---
<br />CITY /TOWN
<br />
<br />. .. .... . ._----Wjfl'O
<br />16c. DATE (Mo., Day, YL)
<br />
<br />II Burial
<br />
<br />o Donation
<br />
<br />afCh-22,- 2006-
<br />STATE
<br />
<br />,,;' 0 Removal 0 Olhar (SpaClfy) Westlawn Cemetery
<br />~ ~UNERALHOME NAMEAN6-MAiLINGADDAESS.(Slraat,CltyorTo~~, State)
<br />,j% A fel Funeral Home 411 West 11th St. P
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />
<br />
<br />Zip Code
<br />
<br />18. PART I. Enter the dJ~'-dis.as.s, injurl.s, or complicallonsuthal diractly caused t~a d..lh. DO NOT anlar terminal events such as cardiac arrast,
<br />respiratory arrest, Dr ventricular librillation without showing ,the etiOlogy. DO NOT ABBREVIATE. Enter only one cauee on a line, Add additional tines if necessary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onset to death
<br />
<br />IMMEDIATE CAUSE (Flnaf
<br />disease or c'onditlon resulting
<br />In d..t~)
<br />
<br />(a)
<br />
<br />Cardio-pulmonary arrest
<br />
<br />15 minutes
<br />
<br />Heart disease
<br />
<br />.---.--."..._.....1
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />
<br />onset to death
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />S.quantlally lI,t condition., If (b)
<br />;l~,ifc :~~;~:a:'lng to the cause listed DU. TO, OR AS A CONSEQUENCE OF:
<br />
<br />;.:i~. Ent..t~.UNDERLYINGCAUSE
<br />.Il, ~: (dls.ase or Injury thatlnltlated (c)
<br />~';'1,j Ihs event. re,ultlng In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />: 'if LPSr
<br />
<br />;l~~~~ _m______ (d)_ ____
<br />1\,,% 18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing 10 Ihe daath but nol resulting In Ihe underlying cause given In PART I.
<br />)'iI~).'~,
<br />,"~;;~~
<br />
<br />'.I.'I'.!.';.II..'.:.....; 20.IF FEMALE:
<br />
<br />~;, .~~
<br />"]1 I
<br />
<br />:~Ir' 0 Unknown if pregnanl wilhin Ihe past yaer
<br />
<br />:~I~ 22;OATE oriNJuRy-iMO" Day, Yr)
<br />.:'{l.i: 22d.INJURY AT WORK?
<br />
<br />unknown
<br />
<br />onsel to death
<br />
<br />onsat to daalh
<br />
<br />.1
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />~ YES 0 NO
<br />
<br />o AccldantO Pending Invesllgatlon
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />o Passengar
<br />
<br />o Padeslrlan
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />o Nol pragnant within past yaar
<br />[J Pregnant at time of death
<br />o Not pregnanl, but pregn'ol within 42 days 01 dealh
<br />o NO! pragnarll, but pragnanl43 days 10 1 year b"ore death
<br />
<br />21a. MANNER OF DEATH
<br />~ Nalural U Homlcid.
<br />
<br />o YES
<br />
<br />JtJ NO
<br />
<br />o Suiclda 0 Could nol ba delarmlned
<br />
<br />o Other (Specify)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />o YES
<br />
<br />XQQ NO
<br />
<br />o YES 0 NO
<br />
<br />
<br />m
<br />
<br />22b. TtME OF INJURY
<br />
<br />22C. PLACE OF INJURY-AI home, farm, slre.t, lactory, office building', construction .ile, elc. (Specify)
<br />
<br />
<br />221. LOCATION OF tNJURi " STREET & NUMBER, APT. NO.
<br />
<br />CiTYIfOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo" Day, Yr.)
<br />March 17 2006
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />..5 - ,_0&
<br />
<br />24b. TIME (1. n..-rH
<br />
<br />m
<br />
<br />z>
<br />~~!i!
<br />_a:
<br />H~
<br />CL n.. 4:( ::J
<br />E _" > z
<br />8ffi!zO
<br />.8z=>
<br />~~8
<br />o.
<br />uo
<br />
<br />1500
<br />
<br />m
<br />
<br />23b. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />23c. TIME OF DEATH
<br />
<br />24c. PRONOUNCED DEAO (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />1516 m
<br />
<br />
<br />23d. To the bosl of my knowladge, daeth occurrad allha lime, dala and plsca
<br />and dualo Ihe cause(s) slaled. (Slgnatur. and Tille)"
<br />
<br />249. On the basis of Bxamination and/or Investigation I In my opinion death ooourred at
<br />the time, date and placa and dua to tha cause!slSl~led. (Signalure anj Tille)'"
<br />'- Ha jY County Attorne
<br />~...".~
<br />
<br />25. DID TOBACCO USE CONTRIBUTETOTHE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />
<br />o YES 0 NO 0 PROBABLY b UNKNOWN 0 YES ~ NO Nol AppUcab!._it..2Se is NO ._ 0 YES ~ NO
<br />.-.-2,-NAME,l'rrlE AND ADDREss OFcERTIFIER (PHysiGil\N, CORONEFi;S PHysiCIAN OR COUNTY ATTORNEY) (Type or Prlnl)
<br />Mark J. Youn , Hall County Attorney, 231 S. Locust St, Grand Island, NE 68801
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />APR
<br />
<br />5 2006
<br />
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