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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 RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECtiON, WHIOH IS
<br />
<br />:::;::~~:::::~TORY FOR VITAL RECORDS. ~."~.."~.."".;- ......... ...:.'.;.'...........:... . ~ ..'~'
<br />FEB 282007 ~v-a~~e'~I'QOPER
<br />2 0 0 7 0 3 327 ASSISTANT sTATE,rFiEGIBTRAR
<br />LINCOLN, NEBRASKA HEALTH ANDHI;JMAN SE1:1V1CEs
<br />, .. .. ,- ~":i,." .
<br />
<br />'. \-'
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<br />'-
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPO T
<br />CERTIFICATr;.,OF DEATH 1l____2.2.LQ1__
<br />
<br />1. DECEDENT'S.NAME (FirS!, Middle, Lesl, Sulllx) 2. SEX
<br />
<br />Charles louis Krurger-
<br />4 CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE.Last Birthday I_~_ ~_~R_l_YEAR
<br />(Yrs) MOS 1 DAYS
<br />Washington, Kansas 72
<br />
<br />7. SOCIAL SECURITY NUMBER 8e. PLACE OF DEATH
<br />
<br />3. DATE OF DEATH (Mo" Day, Yr)
<br />
<br />FabrW!:J:Y_ J9,.2.O.D.L
<br />6. DATE OF 61RTH (Mo., Day, Yr)
<br />
<br />
<br />December 10,1934
<br />
<br />515-28-3200
<br />.-.--------..----- .---
<br />
<br />QI]illJ: Xl Nursing Home/LTC CJ Hospice Facilily
<br />
<br />1:JQSElIAl.:
<br />
<br />CJ Inpatienl
<br />
<br />8b. FACILI'IY-NAME (If nol Institullon, give slroet and numbal)
<br />Grand Island Veterans Hone
<br />2300 vvest Capital Avenue
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island, Nebraska 68803
<br />
<br />N:b~D~N~k~TE '-l~_b~O~:: Hall
<br />
<br />9d. STREET AND NUMBER
<br />1509 Meadow Road
<br />
<br />U ER/Oulpatlant
<br />
<br />CJ Dacadanl's Home
<br />
<br />o 0Cl'\ 0 Olhar (Spacify)
<br />18d. COUNTY OF DEAT. H
<br />Hall CO':l:l!:'Sl
<br />
<br />
<br />
<br />9g.INSIDE CITY LIMITS
<br />
<br />!l!I. YES 0 NO
<br />
<br />91. ZIP CODE
<br />68803
<br />
<br />1 O~~ MARITAL STATUS AT TIME OF DEATH Xl Married 0 Never Merrled
<br />
<br />lOb. NAME OF SPOUSE (First, Mldcle, Lasl, Suffix) If wifa, 91ve maiden name.
<br />
<br />o Married, but separaled 0 Widowed U Olvcrced 0 Unknown
<br />
<br />.JeYCE:! Martens
<br />
<br />11. FATHER'S.NAME (First, Middle,
<br />Fredrick
<br />
<br />Lasl, Sullix)
<br />Krueger
<br />
<br />Middle,
<br />
<br />Melden Surneme)
<br />Good
<br />
<br />12. MOTHER'S-NAME (Flrsl,
<br />Gladys
<br />
<br />V EVER IN U.S. ARMED FORCES? Give dates 01 s.rviceif y.s. 14a.INFORMANT-NAME
<br />(Ye~n~,orunk.)7 /7 /55-10/31/78 Joyce
<br />
<br />15. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE
<br />
<br />OSurlal o Donalion Not Embalmed
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />Krueger
<br />
<br />16b.lICENSE NO.
<br />
<br />16c. DATE (Mo., Day, Yr. )
<br />Febr. 20, 2007
<br />
<br />STATE
<br />
<br />~ Cremetlon 0 Entombment
<br />
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY /TOWN
<br />
<br />o Removal OOlher(Speclly) Central Nebraska Cremation Service, Gibbon, Nebraska
<br />
<br />
<br />17a. FUNERAl HOME NAME AND MAILING ADDRESS (Stteel, Clly or Town, Stele)
<br />
<br />All Faiths Funeral Home,
<br />
<br />18. PART I. Enter the chain of eventsudlseases, injuries, or complicB.tions-.that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiralory arras I, or ventricular fibrillation wllhoul showing Ihe eliology. DO NOT AB6REVIATE. Entar only one cause on a ilna. Add edditlonellines If necessary.
<br />tMMEDIATE CAUSE:
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />onsello death
<br />
<br />IMMEDIATE CAUSE (Flnol
<br />dIsease or condition resulting
<br />in deelh)
<br />
<br />(e) Amyotrophic Lateral Sclerosis.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />1 Year
<br />
<br />onse' 10 daath
<br />
<br />Sequenlleily ilsl conditions, If
<br />any/leading to the cause listed
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury that Initiated
<br />Ihe evenls resulting In death)
<br />LAST
<br />
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onsel fo death
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onsello deelh
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions conttlbuilng 10 Ihe dealh bUI nol resulting in the underlying causa givan in PART I.
<br />CAD, Dysphagia.
<br />
<br />20. IF FEMALE:
<br />o NOI pregnanl wllhln pasl yeer
<br />o Pregnanf alllme 01 deeth
<br />U Not pregnant, but pregnant within 42 days of death
<br />LJ Not pregnant, but pregnanl43 days 10 I year before doalh
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />o YES XJ{NO
<br />
<br />21b.IFTRANSPORTATlON INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />21e. MANNER OF DEATH
<br />jfI Nefural a Homicide
<br />
<br />o AccfdantD Pending Investigation
<br />
<br />o YES
<br />
<br />}aNO
<br />
<br />U Passenger
<br />U Pedestrien
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLETO
<br />
<br />o Suicide 0 Could nof be determined
<br />
<br />o Olher (Speclly)
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />COMPLETE CAUSE OF DEATH?
<br />-'.__ ~_' . ::'_~ ~'I-_ . . .j,,-!,..I yES . ..Q N9
<br />22c. PLACE OF INJURY.At home, farm, Sf reel, faclory, office building, consttuotlon site, elo. (Specify)
<br />
<br />
<br />22d.INJURY AT WORK?
<br />
<br />o YES 0 NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT NO.
<br />
<br />STl'ifE
<br />
<br />liP CODE
<br />
<br />CITYITOWN
<br />
<br />23a. DATE OF DEATH (Mo., Oey, Yr.)
<br />
<br />~E:!)):r:~_}9, 2007
<br />
<br />23b. DATE SIGNED (Mo.. Day, Yr.)
<br />February 20, 2007
<br />
<br />24a. DATE SIGNED (Mo" Dey, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />,ji:i
<br />.cuz
<br />-II:
<br />ll"'o
<br />!H~
<br />g.~ 1'= i!5
<br />uffiz
<br />llZ=>
<br />00
<br />{:.a:.O
<br />o~
<br />(Jo
<br />
<br />m
<br />
<br />23c. TIME OF DEATH
<br />9:00 P.
<br />
<br />m
<br />
<br />24C. PRONOUNCED DoAD (Mo., Dey, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />248. On Ihe basis of examlnallon and/or Investigation, in my opinion death occurred at
<br />Ihe lime, date and place and duelo tha cause(.) "aled. (Slgnelure end Tille) '"
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />o YES XXNO Ll PROBABLY Ll UNKNOWN Ll YES a NO . .Not Applicable If 26a is NO 0 YES 0 NO
<br />----n-NAMf,'j'iTi:F.'iiNp-ADoRESSOF CEFriIFIER\PHysiCiAN:CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Prlnl)
<br />Jennifer King, M.D., Gran Island Vet ans Hane, Grand Island, NE 68803
<br />
<br />28a. REGISTRAR'S SIGNATURE 28b. DATE FtLED BY RIOGISTRAR (Mo., Day, Yr.)
<br />
<br />
<br />FEB 2 6 2
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