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<br />
<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.uFJg~{)NFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATJ~~$'oS1!CTjfilj,~JjICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. m'7'O-~=~_=:-\'~iJ{'~'':L
<br />n_-"o_ ! - - 'A.
<br />DATE OF ISSUANCE 200702804 "- · -0' ~
<br />UAR 2 ~ :~' TiNGEis. CltoiiER
<br />WI 8 Z007 ASSl$TIfti1:s7ttaT1iFiEa{STRAR
<br />LINCOLN, NEBRASKA H1iAltHAND~'" Ht) 'AN sETiVitES
<br />STATE OF NEBRASKA ~DEPARTMENT OF HEALTH AND HUMAN SERVICE&:fINAf.!$ --.- - T ~-3 3 0 4
<br />CERTIFICATE OF DEATH ~"=- -€== - 0--:0_-, - _{L
<br />
<br />1. DECEDENT'S-NAME (Flrsl, Middlo,
<br />Louise Lillian Barg
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Lasl,
<br />
<br />Suffix)
<br />
<br />_~.mTE OF DEATH (Mo.. Day, Yr.)
<br />March 20, 2007
<br />
<br />6. DATE OF BIRTH (Mo.. Day, Yr.)
<br />
<br />2. s~;=-o_,~,-:
<br />Female
<br />
<br />5a, AGE-La.1 Blrlhday 5b. UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />
<br />5c, UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />Miller, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />88
<br />
<br />January 9,1919
<br />
<br />8S. PLACE OF DEATH
<br />
<br />513-16-8003
<br />8b. FACILlTY.NAME (If nor Instltullon, give stroet and number!
<br />
<br />~,
<br />
<br />1iI Inpallent
<br />
<br />QJlilll' 0 Nursing HomelLTC 0 Hospice Fadllly
<br />
<br />o ERloulpslienl
<br />
<br />o Decedenrs Home
<br />
<br />SaintFrancis Medical Center
<br />
<br />8c. CITY OR TOWN OF DEATH (Inolude Zip Code)
<br />
<br />Grand Island 68803
<br />8a, RESIDENCE.STATE
<br />
<br />W.f.D\
<br />
<br />W Olher(Sp.clly)_,_.
<br />8d. COUNTY OF DEATH
<br />
<br />9b. COUNTY
<br />
<br />
<br />91. ZIP CODE
<br />
<br />9g.INSIDE CITY LIMITS
<br />
<br />I3d YES 0 NO
<br />
<br />Hall
<br />
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />
<br />2516 Delmonte Ave.
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH iii Marrl.d 0 Never Mamed
<br />
<br />68803
<br />
<br />lOb. NAME OF SPOUSE (First, Middle, Last, Sulllx) II wile, give mald.n name.
<br />
<br />o Marned, butseparale~ 0 Widowed 0 Dlvorcsd 0 Unknown
<br />
<br />..
<br />m
<br />{!.
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Husband
<br />16c, DATE (Mo.. Day, Yr. )
<br />
<br />March 21,2007
<br />
<br />STATE
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />
<br />Sufllx)
<br />
<br />(Flrsl,
<br />
<br />11. FATHER'S.NAME (FlrSI,
<br />
<br />Edmund Roehrich
<br />
<br />13. EVER IN U,S, ARMED FORCES? Give dates 01 selVlce II y.., 14a,INFORMANT.NAME
<br />
<br />(Yos, no, orunk.) No
<br />15. METHOD OF DISPOSITION
<br />o Burial 0 Donallon
<br />
<br />Arthur Barg
<br />16a. EMBALMER.SIGNATURE
<br />
<br />Not Embalmed
<br />l6d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY /TOWN
<br />
<br />16b, LICENSE NO.
<br />
<br />Il!I Cramatlon 0 Enlombment
<br />
<br />o Rerooval 0 Olhor (Specdy)
<br />
<br />Central Nebraska Cremation Service
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, CIIy or Town, Slate).
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />
<br />Gibbon
<br />
<br />Nebraska
<br />1 7b, Zip Cod.
<br />68801
<br />
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />ee mltructlona an
<br />
<br />18, PART I. Enl.rlh. ~l:1.i!!rl..lll.vJ(I]I~:'dls.e.es,lnJurles, or compllcallon...lhal dlreclly ceu.ed Ihe dealh. DO NOT enl.r lormlnalevenl. .uch ~~ c~~dla~a!~.~.~. .,_
<br />resplralory arrest, or ventricular IIbllllallon wlthoul showing the etiology, DO NOT ABBREVIATE. Entar only one caUlle on elln..Add addlllonalllne.1I necessary.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />omus-Ilo de8.lh
<br />
<br />IMMEDIATE CAUSE (Fllat
<br />disH" IX' condRIon r..uRlng
<br />h dMlh)
<br />
<br />
<br />onsello dealh
<br />
<br />(a)
<br />
<br />~.~ /~)
<br />
<br />onsello dealh
<br />
<br />Sequentially lIelcondltlon., II (b)
<br />any, I.adlng to lhecauII n.led
<br />on IIn..,
<br />Enter II. UNDERLYING CAUSE
<br />(dl..... or InJury \hat Inllleted (c)
<br />lhee.enlt...ullngndealh) DUE TO. OR ASA CONSEQUENCE OF:
<br />lAST
<br />
<br />onoello dealh
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Condlllon. contdbullng 10 Ihe d.eth bul nor r.oulllng In Ihe underlying caus. given In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />DYES )i(NO
<br />
<br />21 c. WAS AN AUTOPSY PERFORMED?
<br />
<br />o YES ~NO
<br />
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<br />
<br />21,\ ~~NNER OF DEATH
<br />.......'l::Ct-Jalural 0 Homicide
<br />
<br />o AccldentO Pandlng Investigallon
<br />
<br />o SUlClda 0 Could not be delermlned
<br />
<br />21b.IFTRANSPORTATlON INJURY
<br />U Dllver/Op.ralor
<br />
<br />o Passenger
<br />
<br />o Pedeslllan
<br />
<br />o Other (Sp.clly)
<br />
<br />21d. WERE AUTOPSY FINDINGS AYAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES NO
<br />
<br />20. IF FEMALE:
<br />
<br />Nol pregnsnl within pa.1 year
<br />
<br />o Pregnanl alllmo ot dealh
<br />
<br />U Not pregnenl, bul pregnanlwllnln 42 days of death
<br />
<br />
<br />o Nol pregnant, but pregnant 43 days to 1 year before d.eth
<br />
<br />o Unknown II pregnant within the pasl y.ar
<br />
<br />
<br />22a. DATE OF INJURY (Mc.. Day,Vr.)
<br />
<br />
<br />22c, PLACE OF INJURY.AI nome, farm, str.ol. latlory, olllce building, conslrucllon sll., .Ic. (Specify)
<br />- .'-.~~~:,.i,f,;;-~:;~~'.~'lI"':'"
<br />
<br />--, .; - ~'--::':--~~';,,':
<br />
<br />22d, INJURY ATWORK?
<br />
<br />22e, DESCRIBE HOW INJURY OCCURREO
<br />
<br />DYES 0 NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />S1i\TE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo.. Day, Yr.)
<br />March 20, 2007
<br />
<br />24a. DATE SiGNED (Mo" Day, Yr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />:itu
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<br />-"'!:!a:
<br />iUlQ
<br />i>-I=
<br />0. it 4( ~
<br />~~~~
<br />uwz
<br />"z:J
<br />-"'00
<br />~a:U
<br />80
<br />
<br />m
<br />
<br />23c, TIME OF DEATH
<br />12:41 P.rn
<br />
<br />24c. PRONOUNCED DEAD (Mo.. Day, Y"! 24d. TIME PRONOUNOED DEAD
<br />rn
<br />
<br />24e, On the basiS 01 examlnallon andlorlnveollgallon, In my opinion dealh occurred al
<br />the time, date and place and due 10 lhe causers) sleted. (Signature and TIll.)...
<br />
<br />RIBUT!) THE DEATH? 26a, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b, WAS CONSENT GRANTED?
<br />(,
<br />YES 0 NO 0 PROBABLY 0 UNKNOWN U YES NO Nol Applicable If 26a i. NO 0 YES U NO
<br />,NA E. TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COU TY TTORNEY) (Type orPnnl)
<br />Gordon Hrnicek,M.D. 729 N NE 68803
<br />
<br />28a. REGISTRAR'S SIGNATURE 28b, DATE FILED BY REGISTRAR (Mo.. Day, Y"!
<br />
<br />p MAR 2 6 2007
<br />
<br />
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