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<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />MAR 1.5 2006
<br />
<br />
<br />~8.. REGISTRAR'S SIGNATURE
<br />
<br />~~C!. YES_ ~_~~_~!ABLY_---'::l UNKN9~ .1 Eo YES '- .0 NO_______ I Nol A~la II 26_a Is NO 0 YES Al NO
<br />27. NAMe, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Prim)
<br />Dr. Thomas Werner 2444 West Faidley Gran~ Island, Nebraska 68803
<br />
<br />24b. TIME OF DeATH
<br />
<br />~4.. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />~j~
<br />ll~O:
<br />I~S~
<br />E.~ t Z
<br />815:,;0
<br />~z:>
<br />-"00
<br />p.rr.o
<br />815
<br />
<br />m
<br />
<br />
<br />~.._,,------
<br />------.
<br />
<br />23.. DATE OF DEATH (Mo., Day, Yr.)
<br />MARCH 31..__ 2006
<br />
<br />2Bb. WAS CONSENT GRANTED?
<br />
<br />2Ba. HAS ORGAN OR TISSUE DONATION BEEN CONSIDeRED?
<br />
<br />24e. On the basis of examlnallon and/or InvBsligallon, in my opinIon dSCllh occurred al
<br />Ih.llm., dal. and pl.ce end due 10 Ih. cau.a(.) slal.d. (Slgnalura and Till. ) T
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) I 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />m
<br />
<br />ZIP CODe
<br />
<br />
<br />''--''---''--'--''---'~-''-'--'--''--~-I'- -
<br />PART II. OTHER SIGNIFICANT CONDITIONS. Condition. conlrlbullng 10 Ih. daalh bUI nol ra,ulllng In Iha undarlylng causa glvan In PART I. . 19. . WAS MEDICA. L. EXAMINER
<br />OR CORONER CONTACTED?
<br />o YES )D NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />; - ~-YJMiilLU!J~ ____.
<br />
<br />'.........'::.,I....f 20. IF F"'~E:- I . ~la. MANNER OF DEATH 21b.IFTRANSPORTATION INJURY
<br />.:'.'. A 0 'iiil'Nall,ral 0 Homlclda 0 Drlver/Oparalor
<br />.~' ',i,i Not pregnant wllhln pasl year /"'To
<br />:, ~ 0 . W' 0 Passengar
<br />:f'.,i.~~:.'t~ PrBgllanl alllme 01 death AccldenlD PendIng lnvesUgallon
<br />.j",-"., 0'. 0 P.daslrian
<br />tVJi';t: Nol pr.gnanl, bUI pragnanl wllhln 42 days 01 daalh 0 Sulcida 0 Could nol ba d.larminad
<br />
<br />:.~.I" .~. 0 Nol pr.gnant. bUI pr.gnam43 days 10 1 y..r balor. dealh LJ Olh.r (SpaClly) ~ ~OMPLETE CAUSE OF OEATH?
<br />
<br />:'i: ": 0 Unknownllpragnanlwlthinlh.pasly.or _____ 0 YES )d NO
<br />!,,": ~r' ----------...-"_'y'_'--------......._.~, ,,~. ,.,., "'--------"-------...,, , ~ _~ ".___.":~_"'''_.~__~_
<br />i..::..... ....[.. 22a. DA. T. E OF INJURY (Mo.. DO.y, Yr.) 2~b. TIME OF INJU.jRYI2'. ~~c. PLA. C. E OF INJURY-AI ham., larm, s"eal, laclory, olllc. bultdlng, cooslrucllon sile, .Ic. (Spoclly)
<br />
<br />~ ~~
<br />'..':'.,.....m'..~......;.... --22d.INJURY ATWOR~? . 22.. DESCRIBE HOW INJURY OCCURReD-' ,.
<br />-t(':';~'iFr~.
<br />i!~:i' 0 YES 0 NO
<br />1~:;1;.(~1. _".~._
<br />:!ti~ 221. LOCATION OF INJURY. STREET & NUMBER, APT. NO,
<br />,{j'~;;~.
<br />
<br />~NO
<br />
<br />o YES
<br />
<br />STATE
<br />
<br />CITYffOWN
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLe TO
<br />
<br />(d)
<br />
<br />onsallo dealh
<br />
<br />IMMEDIATE CAUSE (Final
<br />dls.... or coodillon ro,ulllog
<br />In daalh).
<br />
<br />Saquenllally lIat condltlollO, II (b) _'_ -"_C .____..._
<br />any, I.odlnglo Ihe cau.alt.lad ---OU~-TO, ORAsACONSEQUENCE-OF'
<br />on line a.
<br />Entarthe UNDERLYING CAUSE
<br />(dlaaase or InJury Ihallnlllalad (c) ". '_._..
<br />Ihe events ra8ulllng In daalh) - DUE TO~ OR AS A CONSEQUENEe OF: -
<br />LASr
<br />
<br />-~.&~Uft
<br />~UE TO, OR AS A CONSEQUENCe OF:
<br />
<br />on..llo dealh
<br />
<br />onsello death
<br />
<br />).. Wee fs
<br />
<br />onsBt 10 death
<br />
<br />IMMEDIATe CAUSE,
<br />
<br />Grand Island
<br />
<br />-~~_..,.,--~~-- .-,..- .~------~,_..
<br />170. FUNERAL HOME NAME ANO MAILING ADDReSS ,.. n' ~..
<br />
<br />Westlawn Memorial Park Cemetery
<br />
<br />o Ramoval 0 Olh.r (Spaclly)
<br />
<br />STATe
<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUII4ANSfli,V/QES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAb_ f}Ee.fNJe~-9-!!'ff!..-"',!.v,v1'J;J1,
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATZJSrTQ$,~Ecr.~q~'-W.HICIj},S':_
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . .~'.~.'"".- -i~-C..~-=.:~~._if~ -....:... .~'.. -..-_--.--'".:-.'."-.. .......:.;'.'......r..,..,....:..'................. '........'................
<br />:, '. c'; ,- -c- =~:c .." . .~:./':J.
<br />DATE OF ISSUANCE ~- . " " . -,_ ,;-, -,:;';:"-
<br />
<br />MAR 1 6 2006 20 0 '( 0 1 05 .t.', {A~~iAfj{~~::;~fs;~;;c,11
<br />LINCOLN, NEBRASKA . f{EALr.J1A.ND.Ht;lfL/jAM.~RJQCE.l~i.".l'""
<br />
<br />~_ s'^" DC N""'S"~D''^Rfc"~~~rF7~~';!~N8d~~''D~~~~i~~6 2 2 60 0
<br />
<br />I. DECEDeNT'S-NAME (Flrsl, Mlddla, Lasl S III ).... ...".'......".: '. :~.."..........., :':CC----1 ,".
<br />, u X.c..', ..,,.... 2. SEX.,\~" ,.". 3. DATE OF DEATH (Mo_, D.y, Yr.)
<br />-~~.----.H.eill:L ------SpS . ...... aJi.:'"
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGe-~o'l Blrth~~1:5b' U~OER 1Y~AR ~c: UNDe~ 1 D~ 6. DATE OF BIRTH (Mo.. Day, Yr.)
<br />(Yro.) Mo-s~iiYS HOURS MINS.
<br />
<br />----HillLCountY-----Nebraska . 90-L
<br />7. SOCIAL SECURITY NUMBER -'--'I- __LJulv ~l..2..L2..
<br />ao. PLACE OF DEATH .
<br />507-12-~ ~ 0
<br />. .....-- ---- .__' ; Inpallonl QiliOR ~Nursing Home/LTC 0 Hosplco Facility
<br />6b. FACILITY-NAME (II. nol InSI..IlUllon, glva Olraal and numb.r).
<br />o ER/Oulpall.nl 0 D.'cadenl" Hom.
<br />
<br />Tiffanv Square' r'o ~ 0
<br />,_~__.=..L-"" '_.__ ~ '-I ~ Olhar(Sp.clly)_
<br />Be. CITY OR TOWN OF DEATH (Inoluda Zip Coda) . ..- .----~..-. ---~-
<br />ad. COUNTY OF DEATH
<br />, Grand Island 68803,__,___ Hall
<br />90.RESIDENCE.STATE ~ ------.::----
<br />. I gc. CITY OR TOWN
<br />-lJebraska _"-_ Hall
<br />9d. STReET AN. D. NUMBER. . - ~ -r-
<br />9.. APT NO 91 ZIP CODe
<br />~~l!1sh.. S tree t
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH l!Ma",ad 0 Nevar Morrlld lOb NAME OF SPOUSE (FlrOI, Mlddl., Lasl, sulllx) 11 w"., 9IV~m~~e~ ~ma
<br />
<br />o Marrl.d, bul s.p.ralad 0 Wldow.d 0 Dlvorc.d 0 Unknown
<br />Lucille Matthiesen
<br />11.FATHER'S-NAME (FI ------ .-- r.----~~--~---
<br />Gi.r~t. M..lddla, . Losl, '. Sultlx) 12. MO.THER'S'NAME (Flrsl, Mlddla,
<br />^____ Spiehs Emma
<br />
<br />13. EVER IN U.S, ARMED FORCES? Glvo dal~;-ol.arvl~all ya.. [- 40.INFORMANT.NAME'" -
<br />(Yas, no, or unk.) No
<br />-- ~ --- .-Lucille....s.u
<br />15. METHOO OF DIS. POSITION lB.. EMaALMER.SIGNATURe . .., -~.
<br />y ~ 16b.L1CENSENO.
<br />~8urial o Donallon ____. ~ ::.n;yz,r
<br />
<br />o Cr.mallon 0 enlombm.nl 16d. CeMETERY, CR'EMATORY-OR 01; ER LOC'ATION -CITy / TOWN
<br />
<br />1li..f.e
<br />16c. DATE (Mo., O.y, Yr. )
<br />March 7, 2006
<br />
<br />14b. ReLATIONSHIP TO DECEDENT
<br />
<br />Mald.n Surnama)
<br />Kroeger
<br />
<br />9g. INSIDe CITY LIMITS
<br />YES 0 NO
<br />
<br />
<br />
<br />\
<br />
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