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<br />STATE OF NEBRASKA-DEPARTMENT OF HEALTH
<br />Bureau or Vital Slatl~t1e'
<br />CERTIFICATE OF DEATH
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<br />~ - /10 ~~.,.
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<br />-1
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<br />'101
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<br />200705590
<br />
<br />ST,t,tt 'I'LI NUMUt
<br />
<br />DECEASED - NAME
<br />
<br />f,_st
<br />
<br />/Il41DDLI
<br />
<br />LA$> SEX
<br />
<br />I.
<br />
<br />
<br />2. Male
<br />
<br />DATE Of DEATH 'MO."", DAY, >lA"
<br />J. August 14, 1971
<br />COUNTY Of DEATH
<br />Hall
<br />
<br />UCE WHiff. NfGlO, "'MUle"'''' INDI.........
<br />IHC. t SPfeln )
<br />. Whi te
<br />CITY, TOWN, OR LOCATION Of DEATH
<br />
<br />11. Nebraska
<br />fATHER~NAME
<br />
<br />14 Lu theran Memorial Hospi tal
<br />MAUlED. NEVER MARRIED. SURVIVING SI'OUSE '" W"". GIVI ....10... ....... I ~evers
<br />WIDOWED, DIVORCED, .1'tC1'T' . ( ) /
<br />,. USA 10. Married It Frieda LouJ,.se Fuerstenau
<br />USUAL OCCUPATION t GIV, ''''0 O' WO.' DON' DU""G MO$T O' KIND Of BUSINESS OR INDUSTRY
<br />I:~"'N(; ""'Sal~'s".(51erk IJIo. Clothing and dry goods
<br />
<br />CITY. TOWN, OR LOCATION 'N$ID. CITY "MITS STREET AND NUMBER
<br />Grand Island ,s"c"ygso. NO' 1108 W. 12th Street
<br />Ud. ,...
<br />MOTHER-MAIDEN NAME
<br />
<br />14<.
<br />
<br />7\. Grand Island ].. Yes
<br />STATE Of BIRIM '" NO' '" U.S.A., "AM' CITIZEN Of WHAT COUNTRY
<br />c()UHT1t'( )
<br />
<br />. T braska
<br />SOCIAL SECURITY NUMBER
<br />
<br />II. 506-12-7845A
<br />RfSIDENCE~STATE COUNTY
<br />
<br />II~.
<br />
<br />Hall
<br />
<br />'11"
<br />
<br />
<br />MI~
<br />
<br />LAST
<br />
<br />MtDDlI
<br />
<br />......T
<br />Koch
<br />
<br />Il.
<br />INFORMANT -NAME - RELATlONSH"
<br />
<br />John
<br />
<br />Catherine
<br />
<br />'~iltU 01 'L',O. NO_.. C::'T'Y' 01 'ow..., $tATf, Z"I
<br />
<br />17.. Mrs. FriedaL.- Sievers
<br />'....T I. DEATH WAS CAUSED BY,
<br />I'.
<br />
<br />11~. n08 'lt1. 12th St. Grand Island
<br />IENTER ONl Y ONE CAUSE 'ER LINE fOil (0), (b), AND (e))
<br />
<br />N e 68801
<br />.'...0 IMA r INIUVAl
<br />U'rWU... ONsn AND Of.'"
<br />
<br />(a)
<br />
<br />).
<br />
<br />
<br />CONDITIO.... "A....l (bl
<br />WHit... G.'II'I IISf TO
<br />~~::Ir:.;~T~:i..'ts~~,:~: OUt TO, O. AS . CONSI!QUINCI 0':
<br />lYING ,...U'U lAst
<br />
<br />(<,
<br />
<br />~AOT II. OTHU SIGlllflCANT CONDITIOIlS, COIlDITIONS CONT.IBUTIIlG TO DEATH BUT 1l0T RE.....TED 'AIT III. If fEMAlE. WAS THEil A
<br />TO CAUSE GIVEIl III 'AIT 1(..) 'IfGItAt<<:l III THE 'AST 3 MONTHS?
<br />YES 0 NO 0
<br />
<br />100.
<br />
<br />
<br />'MONTH, DAf, nAI ) HOUIt
<br />
<br />
<br />If YES W"" "NDIHO. CON-
<br />SIDntD '" OITUMINIHO (AU"
<br />0' 01"'"
<br />1ft.
<br />
<br />ACCIDENT, SUICIDE, HOMICIDE,
<br />OR UNDETERMINED I Sl<<I'"
<br />200.
<br />INjUn AT WORK
<br />I JrfC:;lP'T YU 0tI "'0)
<br />
<br />HOW INJURY OCCURRED 'IN',, NATU" O' INJ~" IN 'UT I Of 'All II, IT'M ...
<br />
<br />20<.
<br />LOCATION
<br />
<br />M.2OII.
<br />
<br />. $t.fU O. '.'.e.. NO" (ITY oa 'OWN, Sf.It.
<br />
<br />701.
<br />
<br />CfRTIfICATION- _11' DOY YOA' _1><
<br />'HYS~.:~f.:HOf.D 'Ht TO C
<br />21.. D.C1UI. '"OM 21.. 0
<br />CfRTlftCA TION MW!CAL EXAMINER OR CORONER, 0" ,". ...... CII ""
<br />r:u.Joi.......u~ Of 1l4l 109,v ANO/OI THt INVUTICATtoN. IN MY O'INION,
<br />Ct..," OCCuUtD ON JHt DAn AND Dut to 'HU: CAuSfI$) $TAnD.
<br />210
<br />CERTifiER NAME 'TY" Of "'"''
<br />Wm. M. McGrath
<br />
<br />'AY
<br />
<br />13.
<br />MAILING ADDRESS-CERTIfIER
<br />734
<br />~URIAL, CREMATION, ItfMOVAL
<br />lif't1.':ln.
<br />2... Burial
<br />DATE f MONTH. PAY, YIAI.
<br />
<br />M. D.
<br />
<br />$oTAff:
<br />
<br />Ne
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<br />_~. " IS.
<br />~~:A~. SIGN,AT!JRf ~lIYN4~' / 1889
<br />(~/Y" f/~~f-
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<br />,...ly.....,...,_'_""".""~4~~.....~J...,~:~<L................_,......,_.___"'",.".>.
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<br /> iI.&'.,','.........,
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<br />THIS CE:RTIFIES THE ABOVE TO BE A TRUE COpy OF AN ORIGINAL
<br />CERTIFICATE ON FILE WITH THE STATE DEPARTMENT OF HEALTH.
<br />. .:RtiRE~1JbF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY
<br />. :fOR. VITAL,J~ECORDS.
<br />r.~" .1. "i~\II:;':~~~::,"",;"~"
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<br />DIRECTOR OF VITAL STATISTICS AND ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA Issued Aug. 26, 1971
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