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<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUM!tN SERVICES
<br />SYSTEM, IT CERTIFIES THE B.ELOW TO BE A TRUE COPY OF THE ORIGIN~'''~Qgfleptfflf!..,E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST~TJSTICS SeCTlONioWl'f!CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~:, ~~. " o;Yc ~
<br />
<br />DATE OF ISSUANCE -0 : fO~, : :.
<br />-- TANLEY S. CQC/PER
<br />FEB 2 0 2007 2 0 0 7 0 15 2 0 ASS/STANTSTATE R!iG1S~R
<br />LINCOLN, NEBRASKA HEA,L TH-AN.iJ{HLJ/llf4~;S~CES
<br />
<br />",
<br />",
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE'AND SUPPORT
<br />.SERTI~ICATE OF DEATH '
<br />
<br />OI--21J3A6
<br />
<br />1. DECEDENT'S-NAME (First, Middle, Last,
<br />Mildred Elaine Muhlbach
<br />
<br />. "'~~;::;~": ::,;:~~ ::~: CO",,';;; "'''" [,;~::"_,;,~",,, '~::'" ~:::' ::~:~" '"~: '~:; ;:";", '";;;;"
<br />""To~~;~_ ..~ l ~_A:.:I~:L~EATH 0 Inpalienl
<br />
<br />FACILITY.NAME (II not Inslilution, give slreet and number) 0 ER/Oulpatlenl
<br />
<br />Beverly Healthcare at Lakeview
<br />o CO>. U Olher (Specify)_..
<br />.~-'..._-".
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) I ad. COUNTY OF DEATH
<br />Grand Island 68803 ~ Hall
<br />
<br />9aRES';E:~E::~ka . =r"-COUNTY H~~l . -l':ITYORT~;and Island
<br />
<br />-""9d,STREET AND'NUMBER ...--~...e. '.A..P.._T.."NO 191, ZIP6.C8.-.08DEO 1
<br />1405 Highw.~~West ___L._
<br />lOa, MARITAL STATUS AT TIME OF DEATH 0 Marrl.d 0 Never Marrl.d lOb, NAME OF SPOUSE (Flrsl, Middle, Last, Sullix) II wile, give maiden name.
<br />
<br />Sulllx)
<br />
<br />2. SEX
<br />Female
<br />
<br />3, DATE OF DEATH (Mo" Dey, Yr.)
<br />January 30. 2007
<br />
<br />~:
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<br />~ Nursing Home/LTC 0 Hospice Faclllly
<br />
<br />o Decedent's Home
<br />
<br />gg. INSIDE CITY LIMITS
<br />Xl YES 0 NO
<br />
<br />o Married, bul sepereled q(Widowed 0 Divorced 0 Unknown
<br />
<br />Dale F. Muhlbach
<br />
<br />11 FATfIER'S-NAME (Flrsl, Middle, La", Sulllx) -TI2,MOrHoR'S.NAME (Flrsl, Middle, Maiden ;;u;-~~~
<br />Carl Smith ~ Mary Hysiop
<br />
<br />13 EVER IN us ARMEDFORCES? Give dales 01 serVlcei~INFORMANT"NAME -34b RELATIONSHIP-TO DECEDENT
<br />(Yes,no,orunk) No.~ Glen Muhlbach Son
<br />
<br />--;-5:METH-ODDF--;;-Ii;poSi~ 16a,EM .L.M ;;;-.SIGNA.T~. . .~'. -----r;. ;'66tbLIC.ENSENO. 16c.DATE (Mo,~aY:Yr)
<br />
<br />~Burial o Donallon hnl'II//.1 -_----.l13:Je. __~ebruary ~07
<br />
<br />OCremellon o Enlombmenl lBd.C~~ATORY OTHERLOCATlON ..- .. CITYITDWN STATE
<br />
<br />o Removal Cl Olher (Specily)
<br />
<br />Cameron Cemetery
<br />
<br />Wood River,
<br />
<br />-.-.,.
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slre.1. Clly or Town, Slate)
<br />Apfel Funeral Home 411 West 11th -St.
<br />
<br />18. PAR"T I. Enter the ~ ,0.1 Iil.Y_lID.1iudlseases, injuries, or compllcalionsnlhat dlreclly caused the death. DO NOT enter lerminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular Ilbrlllation without showing fhe etiology. DO NOT ABBREVIATE. Enter only one cause on a line, Add addllionallinas jf necessary.
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />dIsease or condition resulting
<br />In death).
<br />
<br />Soquenll.llyllstcondlllon.,II (b) C~.,. 0 F ()
<br />ony, leading to Ihe oau.ell.led - DUE TO, OR AS A CONSEQUENCE OF: .." .--.-" ---....
<br />on line e.
<br />Enter Ihe UNDERLYING CAUSE
<br />(dl....e or Injury th.llnllleted (c)
<br />the events resulting In death) DUE T.O~' OR AS A CONSEQUEN~.-.-.
<br />lAST
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />~. C ~.~() ,fIA ~ O~..2+-
<br />
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />on,et to dealh
<br />
<br />G-ry-4L.f..!'
<br />
<br />I
<br />I
<br />L..
<br />I onsello death
<br />I
<br />I
<br />
<br />onset 10 death
<br />
<br />Cw'-(i ~~.
<br />
<br />Ii &'--5 C~(~
<br />
<br />;)..,"/ a--r .e..-
<br />
<br />onsello death
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS'Condltlon' conlribUllng 10 Ihe dealh bul nol resulllng in Ihe underlying Oau.. given in PART I.
<br />
<br />o AccidenlO Pending Invesllgallon
<br />
<br />21b.IFTRANSPORTATlON INJURY
<br />o Driver/Operalor
<br />
<br />U Pas,enger
<br />
<br />o Pedestrian
<br />
<br />--=r ---. -
<br />19 WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />DYES Id"NO
<br />----- --
<br />21c, WAS AN AUTOPSY PERFORMED?
<br />
<br />~-
<br />
<br />o YES
<br />
<br />20. IF FEMALE:
<br />CJ1<'OI;r~gnanl wllhln pa.1 year
<br />o Pregnant al time of death
<br />
<br />21e, MANNER OF DEATH
<br />~Iural 0 Homicide
<br />
<br />U NOI pregnant, bul pregnant wilhin 42 d.ys of dealh 0 Suicide [J Could not b. delermined
<br />o Olh.r (Spoclly)
<br />~ Nol pregnant, but pregnanl43 days '0 I year before d.ath COMPLnE CAUSE OF D;5H?
<br />[J Unknown II pregllanl wilhin Ihe pa" year U YES 01fci
<br />- 22:: ~~~_~~ INJu.m::~Mo.:.[)~Y, Yr.) '1~2b: ~~MEOI'-INJU:_~-122C PLACE ~FlNJURY'AI no";'-, 'erm, .Ir.ol, 10010;y, olllce bUltdl';g:const~u..tlon .110, ole (SpeClfY~.
<br />
<br />22d INJURY ATW;]RK? - 22e DESCRIBE HOW INJURY OCCURRED '--
<br />DYES 0 NO
<br />-- --- -- -- --- ---
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO. CITYITOWN STATE
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr,)
<br />
<br />...QL",~) , ;)..ty.?I
<br />
<br />23b, DATE SIGN EO (Mo" Dey, Yr.)
<br />',12-07
<br />
<br />1>~~
<br />"Cc;;n:
<br />l!>-~
<br />,,-if <l ~
<br />5~i=t5
<br />uwz
<br />11'" ::>
<br />~~8
<br />8 ~
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr..)
<br />
<br />-:L1/._""kJ~....
<br />
<br />240, PRONOUNCED D~AD (Mo.. Day, Yr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />m
<br />
<br />24d, TIME PRONOUN CEO D~AD
<br />m
<br />
<br />24e. On the basis of examInation and/or !nvestlgation. in my opinion death occurrad at
<br />Ihellrne, dale and place and duelo the cau.e(,) slaled, (Signalure end Tille) ,.
<br />
<br />26.. HAS ORGAN OR TISSUE DDNATION BE:.~.gQt!~D?
<br />
<br />DYES 0 NO OPROBABi.Y r;i UNKNOWN 0 YES .. . . G.I NO ... ("" .MIt'~
<br />27.NAME, TiTLE AND ADDRESS OF CERTIFIER (PH.VSIr.tAM ~"C~~"R'O PWVSICIAN OR r:OUNTY ATTORNEYf't'f\lpe.o/Prlfilr -
<br />Kenneth Vettel M.D 2116 W. Faidley" Grand Island. NE
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />NOI Applicable il26a I' NO 0 YES I'.ll NO
<br />
<br />68803
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr,)
<br />
<br />FEB 1 6 2007
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