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<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 ORIGIN_E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA ,_~!S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ::'~~~~:'. .
<br />
<br />200700052 :'ft'):<{:~l'~':
<br />
<br />62
<br />
<br />DATE OF ISSUANCE
<br />
<br />MAR ? 4 2006
<br />LINCOLN, NEBRASKA
<br />
<br />
<br />:,::~.
<br />
<br />STATE OF NEBR.A. SKA -..DE. .R...A.. RTMENT.. OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORhC .
<br />._._.w _~9_~_J:lTIFICATE OF DEATH Q 2.3.04~
<br />
<br />1, DECEDENT'S,NAME (First, Mid~lo, last, Suffix) 2. SEX ~.DATEOF~TH (l.1o"ll.y,Yr.)
<br />Alvena LOU1Se Hehnke Female Maron u, ~UUtl
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />50. AGE.Last Birthday 5b, UNDER 1 YEAR 50. UNDER 1 DAY
<br />
<br />(Yrs,) 9 9 'MiS:-[~~'" ':HOUR~J.~INS
<br />
<br />
<br />8a, PLACE OF DEATH
<br />
<br />6, DATE OF BIRTH (Mo., Day, Yr,)
<br />
<br />January 31, 1907
<br />
<br />Campbell,
<br />
<br />NE
<br />
<br />], SOCIAL SECURITY NUMBER
<br />506-32-8662
<br />
<br />U Inpelil;lflt
<br />
<br />-i~!:!;IliB;,
<br />
<br />XJ .Nursing Horne/LTC U.Haapi&a f8CilHy
<br />
<br />HilliffIb.','
<br />
<br />8b. FACiUTY-NA'Mli(lf-;;;;ti~;t~~~-~i;-;;;;;;'.;;;;j numb.ri--J. .
<br />
<br />~J Wedgewood Care Center
<br />~i!t:}
<br />:;::JU 8~:-cii--YOR TOWN OF DEATH (Inolude Zip Code)
<br />:'iM!l Grand Island, 68803
<br />
<br />
<br />',.I,..I.,,~. i,'.r....,.. -;~:~i:;E~;~~: '~m 0 "..~:,"''',. Simon
<br />
<br />
<br />
<br />~I 0 Married, bulsoparated 00 Wldow.d 0 Oivorced 0 Unknown
<br />~,QJ;
<br />J:i:H/?
<br />,1)41:1' 11. FATHER'S.NAME (First,
<br />It~(~ August
<br />'1~~i
<br />I"'I';~'
<br />, t'i)
<br />".~,t,
<br />~Ii
<br />I!I~J!
<br />(:
<br />
<br />"&,,, ..
<br />}'/,J> i
<br />)J~,:
<br />~hP!
<br />
<br />I:J ER/Oulpatlent
<br />
<br />Cl Decedent's Home
<br />
<br />000<\
<br />
<br />IJ Olher (SpeoifyL___
<br />
<br />ad. COUNTY OF DEATH
<br />Hall
<br />
<br />90. CITY OR TOWN
<br />Grand Island
<br />
<br />r..-----.-------'[..--..'--'...--'
<br />ge. APT, NO 91. ZIP CODE
<br />68803
<br />
<br />-. ----.. "'.._--'-~..
<br />lOb, NAME OF SPOUSE (First, Middl., Last, Suflix) If wito, 9ivo maidon nam..
<br />
<br />9g.INSIDE CITY LIMITS
<br />eYES 0 NO
<br />
<br />Wynn
<br />
<br />Middle,
<br />
<br />Last,
<br />Kuhlman
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S,NAME (FirS!,
<br />Anna
<br />
<br />Middle,
<br />
<br />Maiden $urname)
<br />Reiss
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dales of service If yes. 14a.INFORMANT'NAME
<br />(Yes,no,orunk,) No Jim Hehnke
<br />
<br />15. METHOD OF DISPOSITION
<br />~ Burial 0 Donation
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />
<br />-l~ ~l~C~~S~:O
<br />
<br />CITY /TOWN
<br />
<br />o Cremation 0 Entombment
<br />
<br />':~:"::~~::~ORO~~:~
<br />
<br />l.6,c. DATE (MQ.. Day, Yr, )
<br />
<br />March 16
<br />
<br />2006
<br />
<br />STATE
<br />
<br />o Romoval
<br />
<br />o Olhar (Sp.clfy)
<br />
<br />Westlawn Memorial Park
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />
<br />PART L Enter the chaIn of eventsudlseases, InJuries, or compllcetlons--Ihat directly caused the death. DO NOT enter termInal events such as cardiac arrest,
<br />raspiralory arreSl, or venrrlcular fibrillation without showing the atiology. DO NOT ABBREVIATE. Enler only one causo on a line. Add additlonallin.. II n.cessery,
<br />IMMEDIATE CAUSE:
<br />
<br />)<linsello death
<br />
<br />O,1/{ wUf(.
<br />
<br />_ (a)f3..C:i1l ~ S 'TV
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />;?-EE-r
<br />
<br />IMMEDIATE CAUSE (Final
<br />di.e... or condition r.sulting
<br />In doath)
<br />
<br />Sequ.ntially list oondition., if (b)
<br />any, leading 10 Iho eaus. flslod -, DUE TO, OR AS A CONSEQUENCE OF:
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(dl..... or Injury that inltisted (c)
<br />Ihoovontsr.oulllngIn d..lh) DUE TO, OR AS A CONSEOUENCE OF:
<br />LASr
<br />
<br />onSe! to death
<br />
<br />onsallo d.ath
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />18. PART fl. OTHER SiGNIFICANT CONDITIONS.Condition. conlribullng 10 the dealh bUI nol resulting in tho undorlying causo given in PART I.
<br />AOvA-A.iC t:/) A'V2
<br />(J Iflrhlrl. 5 ~WffL. IN5'tr;C",.c/CIUlC y
<br />- rIF'FEMALE: ~ MANNER OF D-EATH
<br />~Ol pregnant wllhin pa" year 4atural 0 Homloide
<br />o Pregnant et lime of doath
<br />o Not pr.gnanl, but pregnanl wilhin 42 day. 01 dealh
<br />o Not pragnant, but pregnanl43 day. 10 1 year before dealh
<br />~...bU:!~nowoJlR'.~n~~~
<br />----. --..---
<br />22a, DATE OF INJURY (Mo" Day, Yr.) 22b. TIME OF INJURY
<br />
<br />8 -8' ~ 0 (p ......... .... 5: 0
<br />-i2d.INJURY ATWORK?"-"lm:'D-ESCRISE HOW INJURY OCCURRED
<br />
<br />__~~=:"~,~~~ f [ -r __0!.fj!{_..J:kU
<br />22f.lOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />t , r.L,_',yJ,,/lrLL.J'
<br />
<br />~WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />o YES 0 NO
<br />
<br />A ~ccidentO Pending Invesllgatlon
<br />o Suloide 0 Could nof bo dat.rminad
<br />
<br />zr, IFTRANSPORTATION INJURY ;vr. WAS AN AUTOPSY PERFORMED?
<br />o Drivor/Op.ralor 0
<br />I:J Passenger 0 YES NO
<br />
<br />o Pedestrian
<br />
<br />21 d, WERE AUTOPSY FINDINGS AVAilABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />o Olher ISpecily)
<br />
<br />
<br />22c. PLACE OF INJURY,Alhoma, farm, stroot, factory, offico building, construcllon slle, .fc. (Specify)
<br />
<br />0!. '- ~ lD < WOO/.) C4< ( ((A/J <<..
<br />
<br />#<.Ar[/.
<br />
<br />,.<., dO~_, A Tft ~~,t yI
<br />tP~~3
<br />
<br />'-
<br />
<br />jN
<br />
<br />CITYIrOWN
<br />
<br />STATE
<br />
<br />G rt.q-..-v1' ..:f} c..+ Alfl
<br />
<br />;IV!.
<br />
<br />z
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<br />]~
<br />t~
<br />"ji:r:::J
<br />Eo.Z
<br />0"'0
<br /><.> c
<br />1l'g
<br />~J!!
<br /><l
<br />
<br />23a. DATE OF DEATH (Mo" Day, Yr,)
<br />!:!~E_C: 1:1.1 }~_.J 006
<br />~. DATE SIGNED (Mo" Day, Yr,)
<br />3- r-(j~
<br />
<br />24c. PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />240. DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />>.~ ~
<br />.cuz
<br />]U;'"
<br />!~@
<br />ct.Q.. 4: ~
<br />EIJ)(:Z
<br />SffizO
<br />1!Z:O
<br />,2~8
<br />8 l;
<br />
<br />m
<br />
<br />23c. TIME OF DEATH
<br />6:36 A.M. m
<br />
<br />24e. On the basis of examina.tion and/or invBstigation, in my opinion death occurred at
<br />the lime, date and plaoe and due to the causers) staled. (Slgnaluro and Tille) T
<br />
<br />~,WAS CONSENT GRANTED?
<br />_,_N~!~pplio.ble If 26a is NO 0 YE~ NO
<br />
<br />68803
<br />
<br />28e, REGISTRAR'S SIGNATURE
<br />
<br />28b. DATE FilED BY REGISTRAR (Mo.. Day, Yr.)
<br />
<br />MAR .2 3 2006
<br />
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