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<br />STATE OF NEBRASKA
<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 Rl!GQ8QON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL sTA7:I!i1Ifeif.f16I;fiijjlfWHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~.. -~y?, 3':'-\=c~'Bj:;~.~.-:::.c.'-~.;~_
<br />
<br />DATE OF ISSUANCE ." ."., ~~ ~,;.".,
<br />C E'. B I) 7 '~oot:...., .2 0 0 7 0 0 9 ~ 7 ; ~-'~"" = TANtW:s. C-lJOPER
<br />I f_ () d i ;4ssisrANT SiAT~ReGjsiR.AR
<br />LINCOLN, NEBRASKA HEA{nJAND HUM~1iI :it#l'i@ES
<br />~,:,". ~~\ ~',:~i:,f?:{fJI/.~~'~::-'. 0"" ,;:;:~
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SE~YtCES FTN....ueEoAND_SUPPORT
<br />.-....-.- c.ERTI.FICATE DE DEATH,~,o', ....-". '..'- ....----D-6.2ll8 7 9
<br />DECEDENTS.NAME (Firs!. Middlo, Last, Suffix) 2, SEX 3, DATE OF OEATH (MD., Day, Yr,)
<br />A!vin ...~d,\V.:!:~. Walter .~ale.. Febr~ary 1. 2006
<br />
<br />"'-
<br />
<br />
<br />Ewing. Nebraska
<br />
<br />5a. AGE.LaS! Birthday
<br />(Yrs.)
<br />
<br />6, DATE OF BIRTH (Mo" Day, Yr.)
<br />
<br />5b, UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />83
<br />
<br />July 1, 1922
<br />
<br />_ 506-g=1~..,.
<br />FACILITY.NAMI: (If not Institution, give streot and number)
<br />
<br />j8~ PLACE OF DI:ATH
<br />J:iQ.SEJIAl"
<br />
<br />o Doc.denl's Hom.
<br />
<br />[j Inp.llent
<br />
<br />QlliEA;
<br />
<br />Kl Nursing Hom./LTC LJ Hospice facility
<br />
<br />o ER/Outpalient
<br />
<br />Grand
<br />
<br />Island 68801
<br />
<br />----'r'"
<br />9b, COUNTY
<br />
<br />".'--,.-- -.,
<br />
<br />L:I CO\ 0 Other (Specify)_..
<br />=rd COUNTY OF DEATH .
<br />Hall
<br />
<br />'-"-=r' - .-.----
<br />9c CITY OR TOWN
<br />Hall Grand Island
<br />- . .- 1ge, APT, NO 91. ZIP CODE --I~g, INSIDEc'ITY liMITS
<br />68801 ~ YES 0 NO
<br />_..'.'_._."..'--""-''''.~ ~.._.., ~ '.,., .--
<br />lOb. NAME OF SPOUSI: (First, Middlo,last, Sufllx) If wifo, give mslden namo.
<br />
<br />Nebraska
<br />9d, STREET AND NUMBER
<br />
<br />140?....'i:IT~h.\<!~."..
<br />10e, MARITAl STATUS ATTIME OF DEATH Xl Married 0 Nevor Married
<br />
<br />o Married, but separaled 0 Widowed 0 Divorcod 0 Unknown
<br />
<br />Laura Urban
<br />
<br />11. FATHER'S.NAME (First,
<br />John
<br />
<br />Middle,
<br />
<br />last,
<br />
<br />SUffix)
<br />
<br />12. MOTHER'S.NAME (First,
<br />Ma!.z
<br />
<br />Middlo,
<br />
<br />Malden SUrname)
<br />Daniels
<br />
<br />Walter
<br />
<br />13. I:VER IN U.S. ARMED FORCES? Give dates of service If yes, 14a.INFORMANT.NAME
<br />(Yes,no,orunk,) Yes 4/1943-10/1945 Pat Shriner
<br />
<br />14b. RElATIONSHIP TO DECEDENT
<br />Daughter
<br />
<br />15, METHOD OF DISPOSITION
<br />Xl Burial U Donation
<br />
<br />-r16~ L1~E~S; ~O~'-
<br />.._~"",._.-
<br />
<br />CITY /TOWN
<br />
<br />16e, DATE (Mo" Dey, Yr. )
<br />~eb~200~_
<br />STATE
<br />
<br />16a.EMB"f)JIGNA;QU . . /), (> /.?
<br />~(l.i-~ .. L!L.- L-~)
<br />16d. CEMETERY, CRE . ORY OR OTHER--~'
<br />
<br />U Cremation U Entombment
<br />
<br />o Removal 0 Other (Spoclly)
<br />
<br />Ewing Cemetery. Ewing. Nebraska
<br />
<br />17a, FUNERAL HOME NAME AND MAiliNG ADDRESS (Slreet, City or Town, Stato)
<br />Livin ston-Sondermann Funeral Home. 601 N. Webb Road, Grand
<br />
<br />PART I. Enler the cllili,rtoJ ,~~"diseasesl inJuries, or CornplicationS--lhal directly caused the death, 00 NOT enter terminal events such as cardiac arrest,
<br />respiralory arrest, or ventricular fIbrillation without Showing the etiology. DO NOT ABBREVIATE. Enter only One cause on a Une. Add additional lines If necessary.
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />in d.ath)
<br />
<br />IMMEDIATE CAUSI::
<br />.k '1 '
<br />..~a~.. Il/.(ilJ\P.;~ tt/tl>~!)
<br />DUE TO, OR AS A CONSEQUI:NCE OF:
<br />
<br />I
<br />I
<br />
<br />I-t;;'nset 10 deelh
<br />I
<br />I_
<br />
<br />. '~-;;-~se;~Ll_-
<br />
<br />I
<br />,
<br />_L
<br />I onsel 10 death
<br />,
<br />I
<br />.--~._-
<br />I onsel to dealh
<br />,
<br />I
<br />
<br />( lJ9l ~k,'W/
<br />
<br />Sequentially Ifs' condition., If
<br />any, leading to th. caus.llsted
<br />on linea.
<br />Enter tho UNDERlYING CAUSE
<br />(dlseas. or injury that Initiated
<br />tho ev.nls resulting In de.th)
<br />LAST
<br />
<br />(b)
<br />
<br />'.'.----.-,.".-
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(c)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(d)
<br />
<br />:8 PART II OTHER SIGNIFICANT-CONDITloNs.conditions conlrl~Ullng to tho dealh but nol;j;~liing In the }n-derIYI~g Ji" gJ in PART 1.~90:A~0:~~~:LC~::~~:D?
<br />
<br />__~/()r_~hllfJijU_Vc;(-~,tl//(r. .IrffCl?dZ'iT' _ I~s _ riYNo .
<br />
<br />20, IF FEMAlE: 21a. MAN~ROF DEATH 21b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMI:D?
<br />o NOI pregnanl wllhln pas I y.ar I(' Iil'ffatural 0 Homicide 0 Driver/Operator .-t""'
<br />OPasaenger 0 YES ~.
<br />[j Pregnant al lime of death 0 AooldentO Pondlng Invesligallon _." _"__
<br />o Pedestrian
<br />o Nol pregnant, but pregnanl within 42 days 01 death 0 Suloide 0 Could nol be dotormined 21d. WERE AUTOPSYFINDINGSAvAllABLE TO
<br />o Not pregnant, bUI pregnant 43 days 10 1 year b.fore death 0 Other (Specl'y) COMPLETE CAUSE OF DEATH?
<br />
<br />o Unknown if pregnent wilhln tile pest year 0 YES 0 NO
<br />
<br />22a DATE OF'INJUR<(M;-, Da~rE OF INJUR:' L.E OF INJURY.At ho-me, la~-"t:o!l: fsclory, olllco b~lId~ng, con~tru~t~on ,Ite, etc,~P!CIfY) ._
<br />
<br />
<br />22d INJURY ATWOR~? 220 DESCRIBE HOW INJURY OCCURRED
<br />DYES 0 NO
<br />--- --- ~
<br />221. lOCATION OF INJURY. STREET & NUMBER, APT, NO,
<br />
<br />CITY/TOWN
<br />
<br />ST.'iTE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo" Day, Yr,)
<br />
<br />[eb ruafLlL-J.90 6
<br />23b, DATI: SIGNED (Mo" Day,)r.)
<br />X 2- -t. -OW'
<br />
<br />24a, DATE SIGNED (Mo" Day, Yr,)
<br />
<br />24b, TIME OF DI:ATH
<br />
<br />
<br />:z..
<br />!'g~
<br />J!~O
<br />J!:l:b..
<br />Q. c. .... :..J
<br />E ftWt z
<br />8[5z0
<br />~z:>
<br />"'00
<br />t2a:U
<br />80
<br />
<br />m
<br />
<br />23c. TIME OF DEATH
<br />1:30 m
<br />
<br />240, PRONOUNCED DEAD (MD., Day, Yr,) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. To the best of my knowledge, dealh:.occurred at the lime, date and place
<br />K end due I~..".I~ ca.use(~)stale.d;~...~.iJ,~7!1. ~ a.' ,d Titl.) .,
<br />
<br />(. -- I(L17 4 nP
<br />
<br />24e. Or1 the basIs of examination and/or Invesligation, In my opinIon dealh occurred at
<br />the time, dato and place and due 10 the causo(s) stated, (Signature and Tille) l'
<br />
<br />25. DtDTOBACCOUSE CONTRIBUTE TO THE DEATH? 26a HAS ORGAN ORTISSUE DONATION BEEN CONSIDERED? 2~b, WAS CONSENT GRANTED?
<br />.Ir- ~ k'
<br />.__l!.2.~~~.0. 0 PROBABL!~~KNOWN . __ 0 YES. _____.~ . NOI Applicable 1126" Is NO l!YE~~.._
<br />27, NAME,1!l!i.AND ADDRESS QF, CERTIFIER (PHYSICIAN, CORO..N ER'S PHYSICIAN OR COUI';ll.Y ATTO~~Y) ~~ .'. ,1 ,', 1 < 1/2:.'- /... (J.'I . ,__
<br />X (fol!( d, >('.,1""(" !hP .1/16 t;'/p?,ft-r:'/dk., C"w....:.11 ,+-'f4/~':(I/lJC:u'(/((it/7
<br />
<br />26a, REGISTRAR'S SIGNATURE 28b, DATE FILED BY REGISTRAR (MO., Day, Yr.)
<br />
<br />
<br />FEB
<br />
<br />3 2006
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