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<br />-""~~~
<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AfI!PcHUMA~fi!f!VICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAk~OfIf>ONJ::Jaf.;.I1JlTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlfl!1c;!fS~~rlflN;' wtI.~~I:!/S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. !1iJk2 ~~~ '{1
<br />
<br />DATE OF ISSUANCE 1J~"!iJTfiL;;;~rCOP.~Eg
<br />OCT 0 2 2006 ASS/STAN! ~TATE R~GtmJ!B
<br />200 61111i8 HEALTIjAN.9'~1!.,SffRV1.C~S
<br />-"='~~i~i~<~&:'f. -: _=-::.--
<br />
<br />LlNCOLN,NEBRASKA
<br />
<br />"_._.,-~-,.- ..
<br />. - .- - ---~. -.-
<br />
<br />
<br />._~TA~E OF NE~.RASKA - DEPAR~~~;I~~~r;~NQ~U~~~I~VICES FIN.I\~GE AND SUPPORTO 6 _~.O 5 9 9
<br />
<br />1,DECEDENT'S.NAME (Flrsl, Middle, Last, Suffix) 2. SEX 3, DATE OF DEATH (Moil Dey, Yr-l
<br />Alberta M. Alberts Female September L4,2U06
<br />
<br />4,-CITY AND ST~;EOR TERR, ,IT, OR'!, OR FOR,EI~N COUNTR, YOFBIRTH" Sa, AG"E .Last BI;t;;d~,Sb' UN-D'~R 1 YE,AR 50. UNDER 1 DAY 6. DATE OF BIRTH {Mo., Day, Yr.)
<br />~awre:c.~ ' N e br aska __ --.:s,) 80 _I~ .. HOURS MINS. Ma..~. 25, 192~
<br />
<br />
<br />7 SOCIAL SECURITY NUMBER l' · PLACE OF DEATH
<br />506-24-4439 llil8.P.l1:A!. 0 Inpatient Q!!jfB: 0 Nursing Home/LTC DHospioeFaclllty
<br />--------- -
<br />8b FACILITY.NAME (It nol Inst,tutlon, g,ve street .nd number)
<br />625 Lane D -- - -- -- W ER/OUlpatient. .X! Docedenl'sHGm.
<br />
<br />
<br />o lXJI\ DOth.r(Speolfy)___
<br />;;I~~; 80" CITY OR TOWN OF DEATH (I~CIUde Zip Code) - . -- . ~C~UNTY OF DEATH--
<br />;" ~f Hastings 68901 __~ms
<br />
<br />',\ .'r 9'RESIDENCE.STATE- --"~-b."COUNTY ---~CCITYORTOWN '..- ..
<br />~ ~J' Ad H i
<br />';t! _ Nebraska .. __ a~ ast ngs
<br />
<br />"IE 9d STREET AND NUMBER - ", -~"e. AP~iIP ~"" -~" 9g.INSIDE CIT, Y, LIMITS
<br />> ti 625 Lane D__ . _.I~~__j~8901. ._.Lx!=l YES ~ ? NO
<br />
<br />, ~ lOa -MARITAL STATUS ATTIME OF DEATH ~ Married 0 Never Married lOb. NAME OF SPOUSE (First, Middle, L.st, Suffix) If wife, give meiden n.me.
<br />'; k Dale Alberts
<br />:: ~ 0 Married, but separated [J Widowed U Divorced U Unknown
<br />, ,
<br />'~' ,~-- -- - ---. .---. --..
<br />'\'~;~, 11, FATHER'S.NAME IFi,.t, Middle, (Firsl, Mlddlo, Maiden Surname)
<br />?Ja'ij Albert Hepler
<br />
<br />!:b,:~r~:' ~3. EVER IN u.s. ARMED FORCES? Give dates of service if yes. 14b. RELATIONSHIP TO. b-ECEDENT
<br />,~Ifli (Yes, no, or unk.) No Husband .
<br />'.'I\"j;.\. --- ____
<br />::~!P,* 15 METHOD OF DISPOSITION
<br />
<br />i;j~1; 0 Burial 0 Donation
<br />
<br />jl Crem.llon 0 Entombment
<br />o Removal 0 Other (Specify)
<br />
<br />
<br />f 6b. LICENSE NO.
<br />1189
<br />
<br />16c. DATE (Mo.. Day, Yr, )
<br />September ..25. 2006
<br />
<br />
<br />16 CEMETERY, CREMATORY OR OTHER LOCATION
<br />B-V Cremation Center
<br />
<br />CITY / TOWN
<br />Hastings
<br />
<br />STATE
<br />NE
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Streel, City or Town, State)
<br />Livingston-Butler~Volland F.H. 1225
<br />
<br />
<br />17b, Zip Code
<br />68901
<br />
<br />PART I. Enter Ihe ~Ii;!,m&--diseasesl injuries, or compllcations..lhat directly caused the death. 00 NOT enter tarminal evenls such as cardiac arrest,
<br />respiratory arrest, or ventriGular IIbrlllafion wlthoul showing the ellology. DO NOT ABBREVIATE. Enter only one ceUSe on a line. Add additional lines I' necessery.
<br />IMMEDIATE CAUSE:
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I
<br />I
<br />..L
<br />
<br />onset to death
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />dis"ase or condition resulting
<br />in deolh)
<br />
<br />(a) Heart Failure
<br />
<br />Immediate
<br />
<br />onset to death
<br />
<br />Sequentlelly list Conditions, If (b)
<br />eny, leedtng to 'he cause listed -----ouETo~6R AS A CONSEQUENCE OF'---
<br />on line 8.
<br />Enterthe UNDERLYING CAUSE
<br />(die.ose or Injury that Inlll.tod (c)
<br />the evenls resulting In death)
<br />I.A'n
<br />
<br />._"_...~ ,~,.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />1.___.
<br />J,-- on,ello death
<br />
<br />I
<br />_------L...
<br />I on'et to desth
<br />I
<br />I
<br />
<br />(d)
<br />
<br />PART II. OHlER SIGNIFICANT CONDITIONS,Condlllons contributing to tho de.th but not resulting In the underlying Gause given in PART I.
<br />
<br />
<br />J;.... m 19. WA'S M'EDICAL EXAMINER-
<br />OR CORONER CONTACTED?
<br />Throat Cancer ~ YES 0 NO
<br />-"-,-,,- ..----..-',..---. ,-,. ... , -_.~.
<br />20.IF FEMALE: 21a, MANNER OF DEATH 21b, IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />IJt Not pregn.nt wilhin past yoar G!:N.fural 0 Homicide 0 Driver/Operalor 0 YES Q NO
<br />o Pregnant at time 01 death 0 AccidentO Pending Investlgetlon 0 pess.nger ...._ .._..
<br />
<br />o Not pregnant, but pregnant within 42 day' 01 deeth 0 Suicide 0 Could not be determined 0 Pedestrlen 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o Not pregnant, but pregnent43 days to 1 yeer before doath 0 Other (Specify) COMPLETE CAUSE OF DEATH?
<br />o Unknown II pregn.nt within Ihe past ye.r 0 YES 0 NO
<br />. 22a' DATE OF IN~URY (Mo , DaY,_Y.r ~~~I:E OF INJU~: ] 220 PLACE OF INJURY.At ~o~e, t,r;';;;et "actory, otllee bUII~mg, constrUOllon s~'--etc (spe~~y~___
<br />
<br />22d INJURY ATWORKJ:22e DESCRIBE HOW INJURY OCCURRED
<br />DYES 0 NO
<br />---. -- ----- -._---~- -"-
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO. CITYITOWN STATE
<br />
<br />ZIP CODE
<br />
<br />230. DATE OF DEATH (Mo.. Dey, Yr.)
<br />
<br />23b. DATE SIGNED (Mo.. Day, Yr,)
<br />
<br />230. TIME OF DEATH
<br />
<br />
<br />24a. DATE SIGNED (Mo.. Day, Yr,)
<br />9/2~/06
<br />
<br />24b. TIME OF DEATH
<br />. .7: 45 "_ A m
<br />24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />m
<br />
<br />Z>-
<br />...~!!i
<br />.a~tt
<br />"'<nO
<br />n~
<br />a, a.. ~ ~
<br />5~i:i5
<br />uUJz
<br />1li55
<br />~a::u
<br />o ~
<br />00
<br />
<br />23d. To the bast of my knowledge, de.th occurred at the time, dale and pleGe
<br />and due to the causers) atated. (Sign. lure and Title)"
<br />
<br />;:~
<br />\~
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />
<br />DYES 0 NO 0 PROBABLY Q:: UNKNOWN 0 YES IlQ NO
<br />27, NAME, TITLE AND ADDRESS OF CERTIFiER (PHYsiciAN, CORONE'R;SPHYSICIAN OR COUNTY ATTORNEY) (Type Or Prinf'"
<br />
<br />Charles A Hamilton
<br />
<br />26", REGISTRAR'S SIGNATURE
<br />
<br />Not Applicable If ~.6. is NO LJ YES .~_.
<br />
<br />
<br />
<br />28b. DATE FILED S EEriA!t20ij6')
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