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<br />STATE OF NEBRASKA
<br />
<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 BEJ;QRD,DNEILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI~$_'$MJ.~oWt:llCH IS
<br />
<br />
<br />::;~i:;;;~~i:ORY FOR V~AL RECORDS M!~~R
<br />A:?S~TfNT STATE~G!5;!~R
<br />LINCOLN, NEBRASKA 20 0 70 2 9 5 " HE"AJ.TH-~~~q/l':'c^!'~ S_ERVlpES
<br />
<br />--
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<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCIo'MfrfSUPP0fl16.....
<br />CERTIFICATE OF DEATH ',"___ U
<br />
<br />32828
<br />
<br />
<br />.1. D~C~D~NT'S"NAM~
<br />Andree
<br />
<br />2. S~X
<br />Female
<br />
<br />3. DAT~ OF D~ATH IMo., Day, Yr.)
<br />Novembe~ 24, 2006
<br />
<br />IFirst,
<br />(1I1MI)
<br />
<br />Middle,
<br />Mohr
<br />
<br />Last,
<br />
<br />Suffi.)
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE-Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY
<br />(Yrs.) MOS. DAYS HOURS MINS.
<br />81
<br />
<br />July 2, 1925
<br />
<br />6. DATE OF BIRTH IMo" Day, Yr.)
<br />
<br />St. Amand, France
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />035-20-8478
<br />
<br />8a. PLACE OF DEATH
<br />liQ.SElIAl. :
<br />
<br />o Inpatient
<br />
<br />illI:IEB: jlI( Nursing Home/LTC U Hospice Facility
<br />
<br />8b. FACILITY-NAME (If not Instllutlon, give Slreet and number)
<br />
<br />o ER/Outpatient
<br />
<br />o Decedent's Home
<br />
<br />wedgewood Ca~e Center
<br />
<br />0=
<br />
<br />o Other ISpeclfy)
<br />
<br />68803
<br />I 9b, COUNTY
<br />
<br />..--...._~_."-.._~:'-~~
<br />
<br />ed. COUNTY OF D~ATH
<br />Hall
<br />
<br />9c. CITY OR TOWN
<br />
<br />Grand Island
<br />
<br />
<br />9g. INSID~ CITY LIMITS
<br />2215 Sheridan Ave. \Ii( YES 0 NO
<br />10.. MARITAL STATUS ATTIME OF DEATH 1ll.Marrlad U Never Merrled lOb. NAME OF SPOUS~ IFlrst, Middle, Last, Sulti.) If wife, give m.iden name.
<br />
<br />o Divorced 0 Unknown Casper Dale Mohr
<br />
<br />Middle,
<br />
<br />Maidsn Surname)
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />Suffi.)
<br />
<br />12. MOTHER'S-NAME (First,
<br />( Unknown )
<br />
<br />No
<br />
<br />14a.INFORMANT.NAM~
<br />Casper Dale Mohr
<br />
<br />14b. R~LATIONSHIP TO D~C~D~NT
<br />Husband
<br />
<br />(Yes, no, or unk.)
<br />15. M~THOD OF DISPOSITION
<br />
<br />
<br />
<br />15c. DATE IMo., D.y. Yr. )
<br />November 29, 2006
<br />
<br />o Burial
<br />
<br />o Donation
<br />
<br />STATE
<br />
<br />Ill1 Crem.tion 0 Entombment
<br />
<br />o Removal OOI~er(Specify) Central Nebraska Cremation Service, Gibbon, Nebraska
<br />
<br />17a. FUNERAL HOM~ NAMe AND MAlLIN!) ADDRESS (Streel, City Of_Town, Stale)
<br />
<br />Kleine Fune~al Home, 3213W North Front
<br />
<br />
<br />. PART I. Enter the chain of events.-disBBSBS, injuries, or complicallons--that directly caused the death. DO NOT enter terminal evenls such as cardiae arrest,
<br />respiratory arrest, or ventricular IIbrlllallon wll~out .~owlng I~e etiology. DO NOT ABBR~VIATE, ~nt.r only on. cause on a line. Add .ddition.1 II nos If nocessary.
<br />
<br />IMMEDIAT~ CAUS~:
<br />
<br />onsello deat~
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />disease or condition resulting
<br />In d..t~)
<br />
<br />
<br />. __________~_~G~fc ~
<br />
<br />I onset to death
<br />I
<br />I
<br />
<br />._....~.J.. .
<br />I onsel to death
<br />I
<br />I
<br />..I..
<br />I onsetto dealh
<br />I
<br />I'
<br />
<br />(.)
<br />
<br />S.qu.ntlally lI.t condition., If
<br />any, leading to the cause listed
<br />on line 8.
<br />~nt.r t~. UNDERLYING CAUSE
<br />(dl..... or tnJury th.t tnlll.t.d
<br />the event. resulting In death)
<br />LAST
<br />
<br />Ib)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(0)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(d)
<br />
<br />18. PART II. OTHeR SIGNIFICANT CONDITIONS'Conditlon, conlributing 10 the deat~ bul not re.ulllng In t~e underlying ceuse given In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />U Y~S lIl"'No
<br />
<br />L~i~.~~~~~"",_C~r}..______
<br />
<br />20.IF FEMALE: CJ 21a.MANNEROF DEATH
<br />Q1(.jural 0 Homicide
<br />
<br />21b.IF TRANSPORTATION INJURY 210. WAS AN AUTOPSY PERFORMED?
<br />o Drlver/Operalor
<br />
<br />IB1fo
<br />
<br />DYES
<br />
<br />o AccldentO Pending Investigation
<br />
<br />o Passenger
<br />o Pedestrian
<br />o Othar (Specify)
<br />
<br />21d. W~RE AUTOPSY FINDINGS AVAILABL~ TO
<br />COMPLETE CAUSE OF D~ATH?
<br />
<br />U Not pregnant, bul pregnant wll~ln 42 day' of deet~
<br />i.J NO! pregnant, but pregnant 43 days 10 1 year before death
<br />o Unknown II pregnant wllhln the past year
<br />
<br />o Suicide U Could not be determined
<br />
<br />DYES
<br />
<br />~
<br />
<br />22.. DATE OF INJURY IMo., Day, Yr.) 22b. TIME OF INJURY
<br />'! I m
<br />
<br />. 22d INJI.IRY ATWORf}? 22; DEsciWiHOW INJURY OCCURRED
<br />
<br />DYE S al'1'1'O
<br />------ - - --------
<br />22f. LOCATION OF INJURY - STR~ET & NUMBER, APT. NO.
<br />
<br />22C. PLACE OF INJURY.AI home, f.rm, slreel, f.clory, office building, construcllon .lIe, elc. (Speclly)
<br />
<br />CITYITOWN
<br />
<br />STi\fE
<br />
<br />ZIP CODE
<br />
<br />23.. DAT~ OF D~ATH (Mo., Day, Yr.)
<br />
<br />24a. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b. TIM~ OF D~ATH
<br />
<br />>~~
<br />J:lUZ
<br />_II:
<br />"2g!P
<br />!il:li~
<br />ECI)(:Z
<br />8l5z0
<br />.8z:J
<br />~~8
<br />80
<br />
<br />m
<br />
<br />240. PRONOUNCED DEAD IMo" Day, Yr.) 24d. TIM~ PRONOUNC~D D~AD
<br />m
<br />
<br />24e. On the basi. of examination and/or Investigation, In my opinion deal~ occurred at
<br />the lime, dale and place and dUB to the cause(s) stated. (Signature and TIlle ).T
<br />
<br />26.. HAS ORGAN OR TISSU~ DONATION BEEN CONSIDERED?
<br />
<br />~
<br />
<br />26b. WAS CONSENT GRANTED?
<br />Nol Applic.ble If 26. i, NO 0 YES ~.tr1JO"'
<br />
<br />NE 68803
<br />
<br />~
<br />
<br />2Ba. REGISTRAR'S SIGNATURE
<br />
<br />2Bb. DAT~ FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />NOV ~ 9 2006
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