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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HI,/MAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL F{EPC!flRJ'!' FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/~IJCSS~TI~HICH IS
<br />
<br />:::;::~::::::;TORY FOR VITAL RECORDS'~fwi=:~
<br />l'ff,.~:?v7JTANL.EY S. C12~ER
<br />MAR 2 2 2UDI-i 2 0 0 6 OS 4 6 5 ASS/$TANT S7'AtE REc,;I$TRAR
<br />LINCOLN, NEBRASKA ~!J.'fttA,,!OHUMAN ,:FRVjCESi
<br />
<br />u.
<br />
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE1\ND SUPPORTO 6 2,2' 4':. 82'
<br />CERTIFICATE OF DEATH .
<br />.'_'~'M.__.. .. ,,~"_"',. ,.",.",,~.~_.,._,___. .".___
<br />DECEDENT'S.NAME (First, Mlddlo, last, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />Selma Minnie Beyersdorf Female March 6, 2006
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />',-.
<br />
<br />5a. AGE-last Birthday 5b. UNDER 1 YEAR
<br />(Y...) MOS. DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />St. Paul, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />504-44-5529
<br />
<br />87
<br />
<br />~eptember 15. 1918
<br />
<br />8a. PLACE OF DEATH
<br />l:iQ.S.f'.!IAI.: LJ Inpallent
<br />
<br />QJl:JEB: 0 Nuralng Home/LTC 0 Hosplco Facility
<br />
<br />8b. FACILITY-NAME (If not Inetltutlon, give stroot ond number)
<br />
<br />00 ER/Outpallent
<br />
<br />o Decedent's Home
<br />
<br />Faith Regional Health
<br />Jj~s t"G~mpus
<br />8c, CITY OR TOWN OF DEATH (Includo Zip Codo)
<br />Norfolk; 68701
<br />
<br />Services
<br />
<br />Nebraska
<br />
<br />19b.cou~all.
<br />
<br />o i:O\ 0 Other (Specify)
<br />
<br />-j 8d, C~~~YiO;:~TH
<br />
<br />- ". '~'~~~"",,,.
<br />
<br />215 W. 10th
<br />
<br />
<br />68801
<br />
<br />9g, INSIDE CITY LIMITS
<br />
<br />~ YES 0 NO
<br />
<br />10a, MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married 10b, NAME OF SPOUSE (First, Mlddlo, Last, Suflix) It wife, glvo maiden name.
<br />
<br />o Married, buf 'eparated ~ Wldowod 0 Divorced 0 Un~nown Louis Beyersdorf
<br />
<br />11, FATHER'S-NAME (Flrsl,
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S.NAME (First,
<br />Dora
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />
<br />(Yes, no, or un~,)
<br />
<br />Wilhelm John . R_~_iJ!l_~~S
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service II yes. 14a,INFORMANT.NAME
<br />No
<br />
<br />Pearl La cock
<br />18..a,..E.M.. B.~ A~ .SIGNATY'E-7)~""
<br />SJ~,,'/1. (.."I,----=
<br />';-8d.'CE~TERY, CREMATORY OR OTHER lOCATioN
<br />
<br />t8b. LICENSE NO.
<br />
<br />15, METHOD OF DISPOSITION
<br />:K:I Burial 0 Donation
<br />o Cremation 0 Entombment
<br />
<br />111196
<br />CITY /TOWN
<br />
<br />Wulf
<br />14b, RELATIONSHIP TO DECEDENT
<br />
<br />.. _Q~),lg):lter
<br />18c. DATE (Mo., Day, Yr.)
<br />March 11, 2006
<br />
<br />STATE
<br />
<br />o Removal 0 Olhor (Spocify)
<br />
<br />Westlawn Memorial Park Cemetery
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />
<br />17a, FUNERAl HOME NAME AND MAILING ADORESS (Street, City or Town, Slate)
<br />
<br />Zip Code
<br />
<br />PART I. Entar tha chain of ElVElnts..dis.ases, Injurle., or compllcatlons--thal dlr.clly caused tho daalh. DO NOT enler lermlnal evenls such aa cardiac arreSl,
<br />respiratory erresl, or v.ntrlcular flbrlllallon wllhoul showing Ihe etiology, DO NOT ABBREVIATE, Entor only on. causo on alin.. Add addilionalllnes II nec.ssary.
<br />
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<br />___~. __ ..1
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<br />2 I Lf.-:r
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<br />IMMEDIATE CAUSE (Fln.1
<br />disease or condition resultlng
<br />In dealh)
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />(a) V"e~:w~
<br />
<br />OUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />OnSat to death
<br />
<br />onsello death
<br />
<br />Sequentially list conditions, Ir
<br />any,l!'illdlng to the cause lilted
<br />On line 8.
<br />Enlort"" UNDERLYING CAUSE
<br />(dl,..,e or Inlury that Initiatod
<br />tha ovonl. ",ultlng In death)
<br />lAST
<br />
<br />E-~:w~~cd
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(b)
<br />
<br />WOWc (
<br />
<br />on,et to death
<br />
<br />(c)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onsel to deeth
<br />
<br />,~~
<br />~~i
<br />;tl~'"
<br />;'uil1:;
<br />~
<br />11""":' 20. IF FEMALE:
<br />'~if
<br />}1~ '(i?'..
<br />':ij~~
<br />1..'.;.'.\.1.".......:1........'.:.:.\.'..'
<br />:~\ .{
<br /><: ' ';, 220, DATE OF INJURY (Mo., Day, Yr,)
<br />f;'_th
<br />I'~IIF~
<br />):.1:1,(:: 22d, INJURY AT WORK?
<br />;,.lJ%,
<br />
<br />~If
<br />'>,!l\f}'
<br />.....;....I..~.'~ ~. '..:.".:.... 221. LOCATION OF INJU. RY. .. STR. EE.T&.. .NUMBER' APT. NO.
<br />
<br />'f .~~.-.- '23a DATE OF DEATH (Mo" Day, Yr.)
<br />'\' , ::;: ,n-:2. ,...., r_
<br />, 'j;':! '-':;.J V~
<br />~! ~ ~ 23b. DArESlaNE.D-(~Mo~:D;y, yr,)
<br />
<br />
<br />'~iW bOO
<br />
<br />
<br />':'>Pi: 25, DID TOBACCO USE CONTRIBUTE TO THE
<br />'!~(l~t,~:
<br />,IS:~;' 0 YES NO 0 PROBABLY 0 U NOWN. . 0 YES ~o
<br />IN,;. 27:'NAME,-Tii'i. AND ADDRESS OF CERTlFIE YSICIAr~, CORONER'S PHYSICIAN OR COUNTY ATfORNEY)'iType or Print)
<br />'S,~h ~10({) W. l--.lorrW\\C !xV. ~ \ W\
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to tho doath but not re'ultlng In the underlying cause given In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />DYES ;: NO
<br />
<br />U Nol pregnant wilhin pasl yaar
<br />o Pregnanl at time 01 dealh
<br />o Not pregnant, bul pr.gnan! within 42 day' of death
<br />II Not pragnent, bUI pregnant 43 days to 1 yoar belore d.alh
<br />o Un~nown If pregnanl within the past yoar
<br />
<br />21a, MANNER OF DEATH
<br />o Noturol 0 Homicide
<br />
<br />o AccidontO Pending Investigation
<br />
<br />21b.IFTRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />o Passenger
<br />
<br />o Pedestrian
<br />
<br />21 c. WAS AN AUTOPSY PERFORMED?
<br />
<br />DYES
<br />
<br />(I NO
<br />
<br />o Suicide 0 Could not be determined
<br />
<br />o Olher (Spaclfy)
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF OEATH?
<br />
<br />DYES
<br />
<br />Xl NO
<br />
<br />22b, TIME OF INJURY
<br />
<br />22c, PLACE OF INJURY-At home, larm, "reet, fectory, office building, conslruction slfe, etc. (Speclly)
<br />
<br />m
<br />
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />DYES 0 NO
<br />
<br />CITYITOWN
<br />
<br />STIIfE
<br />
<br />ZIP CODE
<br />
<br />24a, DATE SIGNED (Mo., Day, Yr,)
<br />
<br />24b, TIME OF DEATH
<br />
<br />m
<br />
<br />z,..
<br />~~!l;!
<br />llUia:
<br />l~~
<br />0- a.. oC( :::i
<br />~ffii~
<br />"z=>
<br />"'00
<br />~ttO
<br />o ~
<br />U 0
<br />
<br />m
<br />
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />
<br />24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />248. On the basis of examina.tlon and/or invesllgatlon, In my opinion death occurred at
<br />tho timo, dalo and place and due to the causer,) "ated, (Slgnaturo and Title) T
<br />
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />28b. WAS CONSENT GRANTED?
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />Nol Applicable If 28a I' ~~.o~ES.9.~_
<br />
<br />Norfolk, NE 68701
<br />28b. DATE FilED BY REGISTRAR (Mo., Day, Yr.)
<br />MAR 1 3 2006
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