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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH~~!M!RVlCES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGIN4t.:lfEQDBD fII{J!fE:g.WlTH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAnsTa-:sEeri6Ni-'WHIl:H IS <br /> <br />=TELE;:=TORYFORWTALRE~ !Pi)~, <br />FEB 1 8 1999 20070227 0 A~TA~~~:~~= <br /> <br />LINCOLN, NEBRASKA HEAL TH ANiJ,1t:tUiU.t(g~~~Ysi;EM <br />STATE OF NEBRASKA. DEPARlMENT OF HEALlH AND H11MAN~ ~UPPORT <br />VITAL STATISTICS ".L~c "=:,-, , --',='~'cj:.",- <br />CERTIFICATE OF DEA TH -~"'--, .~:.::::,:.,.- <br /> <br />1. DECEDENT. NAME <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />LAST <br /> <br />2. SEX <br /> <br />3. DATE OF DEATH IMonth, Oay. Yearl <br /> <br />Roderick <br />.. CITy AND STATE OF 61RTH IHnotln U.SA. n.meaa,mlryl <br /> <br />Donald Huebner <br />50. AGE. LASt Blondoy UNDER 1 YEAR <br />(Y,..) ~. MOS. DAYS <br />65 <br /> <br />Male <br />UNDER 1 DAY <br />5<:. HOURS' MINS <br /> <br /> <br />Februar 5. 1999 <br />6. DATE OF BIRTH (Month.O.y. Yea') <br /> <br />lda Nebraska <br />-: 7. SOCIAL SECURTIY NUMBER <br />. <br />] 507-36-2128 <br />~ 8b. FACILITY. Name <br />. <br />1 . BryanLGH Medical Center East <br />8e. CITY. TOWN OR LOCATION OF DEATH <br /> <br />October 1. 1933 <br /> <br />80. PLACE OF DEATH <br /> <br />HOS.~!~: <br /> <br />~ <br />o <br />o <br /> <br />ER Outoob.nt <br /> <br />InPBtient <br /> <br />Q!HER: <br /> <br />o Nursing Home <br /> <br />o Resloen(;t:! <br /> <br />o Othe1(Sf)6C/fyl <br /> <br />(ff not institvtiOn. grv, strHf ~fJd nurnbl1rJ <br /> <br />DOA <br /> <br /> <br />8<l. INSIDE CITY LIMITS <br /> <br />Lincoln <br />90. RESIDENCE. STATE <br /> <br />Lancaster <br />00, STREET AND NUM6ER l/ncllJ(Jirtg Z;p Cc<i<J) <br /> <br />90. INSIDE CITY LIMITS <br /> <br />Nebraska <br /> <br />August St. 6880 yo.1KJ No 0 <br />13. NAME OF SPOUSE Iff Wile. gllIe maidBn "8mBl <br /> <br />1 O. RACE. (8.g.. White. Black, AmeriCan ~lan. <br />ete,)ISoecllyl <br />White <br /> <br />Tarnick <br /> <br />'5. EDUCATION ISpecdy only o'goo'" grado eomplolodl <br />Elemen1ary, Of r2.ondafY 10.121 COllege 11-40'5.1 <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />MIDDLE <br /> <br />MAIDEN SU~NAME <br /> <br />i Donald <br />- 18. WAS DECEASED EVER IN U.S, ARMED FO~CES? <br />{Yes, no, Or unk,J fI1 yes. gIve Wllr and dates of services) <br />Yes 1957 Mar Huebner <br />'9b. INFO~MANT [STREET OR RFD NO" CITY OR TOWN. STATE. ZlPI <br /> <br />Clara <br /> <br />Sor enfrei <br /> <br /> <br />Island Nebraska 68801 <br />210. "!;THDD OF 04SPDSITtDN 2'b. DATE <br /> <br />21C. CEMETE~Y OR CREMATORy NAME <br /> <br />G9Bu,'al OR.mOv., Febr. 9. 1999 Westlawn Memorial Park <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br /> <br />Livin ston-Sondermann F.H. <br />22b. FUNERAL I10ME ADDRESS (STREET OR RF.D NO CITY OR TOWN. STATE. ZIPI <br /> <br />o Ctem.lion 0 OonallO/'l <br /> <br />Grand Island Nebraska <br /> <br />. <br /> <br /> <br />Island Nebraska 68803 <br />IENTER ONLY ONE CAUSE PER LINE FOR 101.lbl. AND lell <br /> <br />Interval between onsel aM death <br /> <br />J <br />t <br />~ <br />[ <br /> <br />lntetval between onset and deafh <br /> <br />Inte(val between Onset and o~an' <br /> <br />0 Accident 0 <br />0 Sl,Iicide 0 F'enl1ing <br />0 Homicide lnvfstu;Jallon <br /> <br />26g. LOCATION <br /> <br />STREET OR R.F.D. NO <br /> <br />CITV OF! TOWN <br /> <br />STAlE <br /> <br />270. DATE OF DEATH (Mo..o.y y,) <br /> <br />Fe-bru..o..r 5 ,qqq <br /> <br />280 DATE SIGNED IMo.Ooy Y<./ <br /> <br />28b. TIME OF DEATH <br /> <br />27e TIME OF DEATH <br /> <br />E"!;; <br />u~ <br />Ugg <br />l!ffi~ <br />~h <br /> <br />M <br /> <br />.. "'! <br />~ I ~ g 2'J.7eq'7q Iq O.y <br />~1lf <br />._ ~ .:c 27d. to the best of my knowledg <br />.. ". .eo..use/sl staled. <br />J <br />(~~gn~lUre and Title ... <br />- 29. DID TOBACCO USE CDNTRIB <br /> <br />DYES ~NO <br /> <br /> <br />28c:. PRONOUNCED DEAD IMo.. Day, Yr., <br /> <br />26d. PRONOUNCED DEAD (Houri <br /> <br />M <br /> <br />M <br /> <br />28e. On the baSiS of examination and/Of investigation, in my opinion death oeeuffea at <br />the time. da1e and place and due 10 the causels) stated. <br /> <br />YES 0 NO <br /> <br />IV) 10 ~ 8S0b <br /> <br />32b. DATE FILED BY REGISTRAR (Me.. O.y. Yr) <br /> <br />FEB 1 6 1999 <br />