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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTHANpH(JMA.N SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RlteiJFliloN FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI$~iffi:ffiON;~WHICH IS
<br />
<br />::;;:::~:::::~TORY FOR VITAL RECORDS. _'...' .~:\~.?~?I~_~.:-. ~....~
<br />APR J 0 200R 'r!7!4TAN~Y--S. a~~R
<br />2 0 0 7 0 0 0 5 6 4S$~$TA#T$TATcE_~GtR'fiMR
<br />. H~t~'(~~!,HIJMAN~Eif~#ES
<br />
<br />-...
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />::.'--~
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FfNA_NGIi~...N_.D sUPPo1)' 6 723
<br />___-'__ CERTIFICATEOFDEA~__' '. '_ 23___~__
<br />1. DECEDENT'S-NAME (First, Middle, Last, Sulflx) 2. SEX 3. DATE OF DEATH (Mo" Day, Yr.)
<br />_Robe_~~ Devern Stahlneckeru_ Male April 4. 22~_
<br />
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a. AGE-Last Birthday 5b, UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />
<br />83
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo" Day, Yr.)
<br />
<br />June 17,1922
<br />
<br />508-18-5678
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<br />6a, PLACE OF DEATH
<br />IiQ.Sf'l!Ab :
<br />
<br />~ Inpatient
<br />
<br />~; U Nursing Home/LTC 0 Hospice Facility
<br />
<br />FACILITY-NAME (If not Institution, give street and number)
<br />
<br />o ERIOutpallent
<br />
<br />o Decedent', Homo
<br />
<br />St. Francis Medical Center
<br />
<br />o [J)\ OOther(Speclfy)______,
<br />
<br />fBd COUNT~:;~ATH ---
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<br />Bc,CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />
<br />- ge.RE~D:~C;,:T::~~~==r::;al1
<br />
<br />90, STR~ET AND NUMBeR
<br />2324 N. Huston
<br />100 'MARITAL STATus'liT-TIME OF DEATHX:XM;;rled (J Nev~;'Marrled
<br />
<br />-~;CITYORTOWN
<br />.~ Grand Island
<br />
<br />,____ ~T:NO[:;;~3
<br />
<br />10b. NAME OF SPOUSE (Flrsl, Middle, Last, Sulflx) If wile, give maiden name.
<br />
<br />-] 9g. INsiDE CITY LIMITS'
<br />i! YES 0 NO
<br />- -..,..
<br />
<br />o Divorced 0 Unknown
<br />
<br />Virginia Kirkpatrick
<br />
<br />------ Fra~~~in s~~~~~eCk:;f;,X),.y:-MoTH~R'S-NA~~;_~rst,
<br />
<br />1 yEVER IN U.S, ARMED FOBCES? Give dates 01 ,ervlce if yes. 14e. INFORMANT-NAME
<br />(Y.s~n~,orunk.) 12/2/1942-11/9/1945 Virginia Stahlnecker
<br />t5 METHOI;-OF DISPOSITION-'~- t?"1MBAL.-.MEB-SIGNATURE . '-'.. '-.' '.. .--I.t6b' LICENSE NO.
<br />m Burial 0 Donation 7~'2--.~<"('~.-z--''-<!.i::-t . _ 1143 .
<br />U Cremation 0 Entombment 160. CEMETERY. CREMATORY OR OTHER LOCATION CITY I TOWN
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />Gross
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />16c, DATE (Mo" Day, Yr.)
<br />April 7. 2006
<br />
<br />STAT~
<br />
<br />o Ramoval 0 Other (Specify)
<br />
<br />Grand Island City Cemetery
<br />
<br />Grand Island. Nebraska
<br />
<br />17;;. FUNEflAL H'OME NAME ANDMAH.lNG ADDRESS-~(Slreet, Clly orTow~,"Slate)
<br />Livingston-Sondermann Funeral Home, 601
<br />
<br />PART I. ~nter the ~_Qf, el'llllll;--dl.e..es, Injuries, or compllcatlons--that directly cau,ed Ihe death, DO NOT enfer fermlnal evenfs such as cardlec arresl,
<br />respire tory arrest, or ventricular IIbrlllation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on aline, Add additional lines if nece,sery,
<br />
<br />I
<br />I
<br />
<br />I onset 10 death
<br />IK
<br />fklLVj
<br />
<br />IMM~DtA T~ CAUSE (Final
<br />dIsease or condition resulting
<br />In de.th)
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />~a) S~~t~/ i (
<br />
<br />DUE TO, OR AS A CONS~QUENCE OF:
<br />
<br />onsello death
<br />
<br />ShE I,
<br />
<br />.t1"U
<br />
<br />(bl (J,l.efA /lY! .vn I t,
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Sequentially list conditions, If
<br />any, leedlng to the cau.e listed
<br />on Iln~ a.
<br />Ente, the UNDERLYING CAUSE
<br />(df.e..e or Infury that Initiated
<br />the even" ,e.ulllng in death)
<br />lJ\Sf
<br />
<br />onset 10 death
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contrlbuling 10 the dealh buf nol resulling in the underlying cause given In PART I.
<br />
<br />19, WAS MEDICAL EXAMINER
<br />..r OR CORONER CONTACTED?
<br />o Y~S ~~O
<br />
<br />/.9n
<br />. ~VI ,
<br />:\Th;J~;'-.~,- . -,"-''''--.'.
<br />iil'~' 20. IF FEMALE:
<br />~.~.\ ~.: 0 Not pregnant wHhln past year
<br />~i' ,,oj 0 Pregnant at time of dealh
<br />':t~'tt [) Not pregnant, bUI pregnant within 42 days of death
<br />{'.~ 0 NOI pregnant, but p'egnanl43 days 10 t year belere death
<br />O'Onknown Trpmgnant within the past y8'8:r
<br />.: 22a. DATEoFlNjuRY (Mo., Day, Y~ME OF INJUR:
<br />
<br />1:0. ',;".'~"m M_- t"~""'"OW '''"'' 000""","
<br />
<br />~: 0 YES 0 NO
<br />":~!#J: -- ~ .,-
<br />;1' 221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITYITOWN
<br />
<br />
<br />:~~ ~:"'--- 23a, DATE OF DEATH (Mo" Day, Yr.) Z >-
<br />1}rt'!,! ~:$ April 4, 2006 ~~!Ii m
<br />
<br />
<br />I n~ ~: ;';:~:f:~;;;~~::,:~::~~~;;:~,~::':::"';, m ~ ::;~~;;;;~;;:~~,~~~~;;';~;;'~,;,,~
<br />
<br />""!J{!.,, (<1 A. {!.a:U
<br />"''i:i1ir'.. '" I 1 tJ ,..-' 10 8 ~
<br />,;rj!f; ___ 1-'1 -"< . ..-"-:
<br />VI::~j,' 25. DID TOBACCO USE CONTRIBUTETOTljE PEATH? ~ HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />;t~ll: X' - -----Ai'
<br />;!;>'~:'-27 ~A~:,SflTl:E~N~~D~f6~E~~~FIER~P~;S~~I~:'6oRONER~ P:~~CiANOR COUNTY ATi%RNEY) (lieeor Print)
<br />,,,i-::, V T ..fl r t'..", 'J )~ .4" t *' (-) (A;': ( /1/(:". ti< lif''::;>
<br />
<br />
<br />(' ,~"'~"'".;:::""'., , . . "- ,-, -J ::~:~6"2~~~":,'"
<br />
<br />2~a.~NER OF DEATH
<br />~ Calu"l 0 Homicide
<br />
<br />(J AccldenlO Psndlng Investigation
<br />
<br />2tb,IF TRANSPORTATION INJURY 2tc, WAS AN AUTOPSY PERFORMED?
<br />U DrlverlOperator X-
<br />
<br />o Passengef U YES
<br />
<br />U pedestrian
<br />
<br />l~fNO
<br />
<br />o Suicide (J Could not be delermlned
<br />
<br />2td. WE BE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />o Other (Specify)
<br />
<br />COMPLETE CAUSE OF DEATH?
<br />o YES )f'NO
<br />
<br />
<br />22c, PLACE OF INJURY.AI home, farm, ,treet, tactory, office building, construction sile, etc. (Specify)
<br />
<br />SlJITtO
<br />
<br />ZIP CODE
<br />
<br />24a, DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />26b, WAS CONSENT GRANTED?
<br />Y
<br />Not Applicable U 26e is NO q YES I VNO
<br />/4
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