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<br />STATE OF NEBRASKA
<br />".. : ",", .,',:
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HI1ALTH AND 1:lJiMit4N'~m;ES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RE.eiJRD:D,i:FltiE_WfrH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM; VITAL STATISTIc.j-~fc.it(jiii~*-JSto,
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. .j': _~:_~0.J<":O" ~ ~~~
<br />
<br />
<br />DA~u,;;"rt;~;6 200702320 ~T,4JiiS:'~~..
<br />
<br />ASSISTANT STATEREGISTRAFi
<br />LINCOLN, NEBRASKA HEALTH ANp HUMAN SERVICES:'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPP~~.' "', .'V',<)..fi'c-tf
<br />CERTIFICATE OF DEATH lI}tO\ L._0':;)"}.)9
<br />
<br />
<br />1. DECEDENT'S-NAME (First,
<br />Hildegarde Anna Hedwig Walker
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />Surllx)
<br />
<br />2. SEX
<br />Female
<br />
<br />Sa. AGE-Last Birthday
<br />
<br />(Yrs.)
<br />
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />W..,!
<br />1C;:l
<br />1\; )
<br />(D
<br />110",'
<br />Il.I'~ a:
<br />if",:~
<br />:~~
<br />1\,:16
<br />iJ"i~
<br />, . a:
<br />i~, :r.~
<br />iC :~ i!
<br />J::.~
<br />ii,i'lj
<br />.~ 'l~
<br />Ie ~i
<br />'"
<br />~
<br />E
<br />8
<br />&:
<br />~
<br />
<br />Germany
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />83
<br />Sa. PLACE OF DEATH
<br />
<br />~:
<br />
<br />~ Inpallent
<br />
<br />Qll:IW: 0 Nursing Homo/LTC 0 Hospice Facilily
<br />
<br />o Decedenl's Home
<br />
<br />506-26-9803
<br />
<br />Bb. FACILITY-NAME (If nol Inslllullon. glv. slre.t and number)
<br />
<br />o ER/outpatlent
<br />
<br />Saint Francis Medical Center
<br />
<br />UroI
<br />
<br />Be. CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />Bd. COUNTY OF DEATH
<br />
<br />Grand Island 68803
<br />Sa. RESIDENCE.STATE
<br />
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />
<br />fib. COUNTY
<br />
<br />
<br />Hall
<br />
<br />1414 Windsor Road
<br />lOa. MARITAL STATUS ATTIME OF DEATH ~ Married 0 Never Married
<br />
<br />91. ZIP CODE
<br />68801
<br />
<br />3. DATE OF DEATH (Mo" Day, Yr.)
<br />
<br />August 13,2006
<br />
<br />6. DATE OF BIRTH (Mo" Day, Yr.)
<br />
<br />November 5, 1922
<br />
<br />o Olher(Speclfy)_____
<br />
<br />o Marned, bul separaled 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Kenneth J Walker
<br />
<br />lOb. NAME OF SPDUSE (First. Middle, Last, SlIlflx) If wife, give maiden name.
<br />
<br />9g.INSIDE CITY LIMITS
<br />Oil YES 0 NO
<br />
<br />Middle,
<br />
<br />1 t. FATHER'S.NAME (Flrsl,
<br />Franz Schaar
<br />13. EVER IN U.S. ARMED FORCES? Give dales olseIVice ilyes.
<br />
<br />Lasl,
<br />
<br />Sulflx)
<br />
<br />12. MOTHER'S-NAME (Flrsl,
<br />Martha Dubberke
<br />
<br />
<br />(Yes, no, or unk.) No
<br />15. METHOD OF DISPOSITION
<br />
<br />IXl Bunal
<br />
<br />o Donalion
<br />
<br />U cremation U Enlombment
<br />
<br />o Removal 0 Olher (SpecllY)
<br />
<br />Grand Island City Cemetery
<br />
<br />t7a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreel, City orTown, Slale)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />
<br />Grand Island
<br />
<br />Middle,
<br />
<br />".,_t.
<br />
<br />Malden SUrname)
<br />
<br />/
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Husband
<br />
<br />16c. DATE (Mo., Day, Yr.)
<br />
<br />August 17,2006
<br />
<br />STATE
<br />
<br />Nebraska
<br />
<br />t 7b. Zip Code
<br />68801
<br />
<br />CAUSE OF DEATH (See instructions and examples)
<br />1S. PART I. Enler Ihe chain 01 evenls--dlseases, Injuries, or compllcations..thal directiy caused the dealh. DO NOT enler terminal events such as cardIac arros,
<br />respiratory arresl. orventrlcularJibnllallon wllhoulshOwlng Iho etiology. DO NOT ABBREVIATE. Enteronly one cause on a line. Add addlllonalllnes If necessary.
<br />
<br />IM",EDlATE CAUSE (Fhal
<br />dlse.oe orcondnlonreeulllng
<br />hde.lh)
<br />
<br />
<br />(,cl;L."lJL...-
<br />
<br />SequenUelly lIotcondlllono,lf (b)
<br />.ny, le.dlng to Ihe cauoe Iloted DUE TO, OR AS A CONSEQUENCE OF:
<br />on line ..
<br />Enlerlhe UNDERLYING CAUSE
<br />(dls..se or Injury IhellnlUated (0)
<br />the evento resulllng Indeelh) DUE TO, OR AS A CONSEQUENCE OF:
<br />IJ'Sf
<br />
<br />(d)
<br />
<br />a:
<br />lid
<br />u..
<br />~
<br />UJ
<br />U
<br />~
<br />"tJ
<br />$
<br />'"
<br />is.
<br />E
<br />o
<br />u
<br />&:
<br />~
<br />
<br />t 8. PART) OTHER SIGNIFICANT CONDITIONS-Conditions conlributlng 10 Ihe dealh bul nol resulllng in Ihe underlying cause given In PART I.
<br />
<br />1-r:Ui"~<Z e:;hL4.L~ (; --~(~;.~dj>. 'Jz,~JM?,fi~",,1 C2r.caa("Gtil..
<br />
<br />20. FEMALE: 21a. MANNER OF D.ATH 21b.IFTRANSPORTATION INJURY
<br />"(l..Nalural 0 HomICide 0 Dnver/Operalor
<br />Not pregnanl within pasl year V
<br />
<br />o Pregnanl altlme 01 dealh 0 AccldenlD Pending Inves~gatlon 0 Passenger
<br />o pedeStHan
<br />o Nol pregnant, bul pregnant Wllhln 42 days 01 dealh 0 Suicide tJ Could not be delennlned
<br />
<br />U Nol pregnanl, bul pregnant 43 days 10 1 yearbelore dealh
<br />
<br />o Unknown II pregnant within the pas I year
<br />
<br />o Olher (SpecHy)
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />onsel 10 dealh
<br />
<br />&; tJe e/(~
<br />
<br />onsello dealh
<br />
<br />onsel to dealh
<br />
<br />onsel to dealh
<br />
<br />t9. WAS MEDICAL EXAMINER
<br />OR CORONER CONJACTED?
<br />o YES ~O
<br />
<br />21c. WAS AN AUTOP~Y PEjOAMED?
<br />DYES e;ro
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES 0 NO
<br />
<br />22a, DATE O~ 1t;.JuP.'l.~"'~,.o.y, Y<.) .
<br />
<br />22!:-. TIME 0, It>l.itlAV He. ~ioi\Gi:: Or INJUkY.Athome: r'arm;-slre.-r. lactory, olllce bUilding, construction slle, etc. (Specify)
<br />
<br />m
<br />
<br />22d. INJURY AT WORK?
<br />
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />U YES U NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBm, APT. NO.
<br />
<br />GITYITOWN
<br />
<br />~
<br />
<br />Z
<br />1;':$
<br />is!
<br />\lg!
<br />c.:t:~
<br />E"-z
<br />8 g'o
<br />!'g
<br />0"
<br />....=
<br />ol
<br />
<br />23a. DATE OF DEATH (MO" pay, Yr.)
<br />August 13, 2006
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />Z'"
<br />olw
<br />,.,- z
<br />.a~1I:
<br />iUlo
<br />"ii?il:
<br />a.a..oc(~
<br />E...... Z
<br />8ffj!;;O
<br />"Z:;>
<br />~~8
<br />o ~
<br />U 0
<br />
<br />SlJITE
<br />
<br />ZIP CODE
<br />
<br />24b. TIME OF DEATH
<br />
<br />23b. DATE SIGN.D (Mo., Pay. Yr.)
<br />Au S 15,.2006
<br />
<br />23c. TIME OF OEATH
<br />1:40 p.rn
<br />
<br />24c. PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIM. PRONOUNCED DEAD
<br />rn
<br />
<br />rn
<br />
<br />24e. Oh Ihe basis olexamtnaUon and/orlnvestlgallon,ln my Oplhlon dealh occurred at
<br />the lime, date and place and due to the cause(s) Stated. (Slgnalure and Tille) T
<br />
<br />
<br />26a. HAS OA13AN OR TiSSU. DONATION BEEN CONSIDERED?
<br />
<br />Nebraska
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />----~
<br />
<br />28.. REOGISTRAR'S SI13NATURE
<br />
<br />p
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />Not Applicable If 26. Is NO 0 YES 0 NO
<br />
<br />68803
<br />
<br />AUG 1 8 2006
<br />
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