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<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL R.I;PO/fOg,NfltItiW!TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISr~-$ECm>N:~:(S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~"..'."-.' ......... '",'.> ",' ," J" ~71~.:,;,t~}t,,:
<br />DA TE OF ISSUANCE JO. , ~",'o '"'
<br />MAR 2 2 2002 2 0 0 7 0 6 3 2 1 :: -:: ~'-EY.s.eooPi~
<br />ASSI1tTIfN-T STA TE REGISJifjIf'i
<br />LINCOLN, NEBRASKA HEALTH AND HfiMANSEB.'(I~~yStE~
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTII AND HUMAN SERVICES-WANeE7lND SHPPoRT
<br />CERTI~~~~~~EATH-.o~.~~,~~~~ ". 01
<br />
<br />~:,'-'
<br />a
<br />\,~ a
<br />
<br />Hazard, Nebraska
<br />
<br />(Yr!; I
<br />
<br />73
<br />
<br />UNDER 1 YEAR
<br />5b MOS I DAYS
<br />I
<br />
<br />
<br />14319
<br />
<br />1 OECEO[NT. NAME
<br />
<br />fiRST
<br />
<br />MlnDl.F
<br />
<br />LAST
<br />
<br />'2SEX-
<br />
<br />3. DAlE OF DEATH (MoNti, Dav. Year)
<br />
<br />Wilma
<br />
<br />Levine
<br />
<br />Lemburg
<br />
<br />Female
<br />
<br />2001
<br />
<br />1.\ CITY ANO'"S-r AlE OF SIR T'H (If not in USA. name country!
<br />
<br />5~j,~. ii'(~E Last Bit1hday
<br />
<br />6. DATI:: OF BIR1H IMonth, Day Yeflr!
<br />
<br />November 13, 1928
<br />
<br />7wCiA'L 'SECURlIY NLJM~l:.H
<br />
<br />Hall
<br />
<br />
<br /> 8. PLACE OF DEATH
<br /> HOSPITAL D
<br /> D
<br /> D
<br />8d INSIDE CITY LIMITS
<br /> Yes [XI No
<br />
<br />Ir"Ip,11Ienr
<br />
<br />OHlfH rn N(Jf5lng rlor"'-'e
<br />
<br />D Aeslc:laf1Ce
<br />
<br />D Other ,SpeclfV!
<br />
<br />508-30-6358
<br />
<br />~LITY-~Namefi
<br />
<br />{If nor institutiOn, give street ~nd number}
<br />
<br />ER Outpatient
<br />
<br />St. Francis Memorial Health Center
<br />
<br />DOA
<br />
<br />8c CITi"r'OWN OR LOCATION Of D~TH
<br />
<br />Grand Island
<br />
<br />Hall
<br />90":" '5'T'AEE'i'""AND NUMBER (fnGluding Zip Corlel
<br />
<br />ge INSIDE CITY LIMITS
<br />
<br />98, RESIDENCE. STATE
<br />
<br />
<br />Nebraska
<br />
<br />Cairo
<br />
<br />68824 ye,lKJ No D
<br />1:l NAME O~ $POUS~ (If Wife. give maid~n n~meJ
<br />
<br />10
<br />
<br />11. ANCESTRy 19.9. Itahan. Mexican, German. elr:1
<br />
<br />etCllSOeWhite ~nca'ian/Irish/ French
<br />
<br />1"a. USUAL OCCUPA liON {Gille kind of wOrK rJOrle (Jurirlq mos'
<br />of WOrklfl(l life, evstt If rerrrM)
<br />Manager Cairo Bowl (Bowling
<br />
<br />16. r Po 1 HER - NAME FIRST ~MiDDLT.~~" LAS 1 1 7 MOTHER
<br />
<br />Willis A. Lemburg
<br />
<br />'5. EDUCATION (SpaClfy only highest grade completM)
<br />Alle ) Elemy'1Y 0' Secondacy 10.121 1 College 1140' ,-,
<br />
<br />FIRST MIDDLE MAIDEN SURNAME
<br />
<br />Henry
<br />
<br />16 WA'; DfCFASEO EVER IN u.S. ARMED FORCES'
<br />(YN~' Or unk.l III yes. give war and dates of services)
<br />
<br />
<br />Minnie
<br />
<br />Brewer
<br />
<br />-NAME
<br />
<br />190 INFORMANT
<br />
<br />MAILING ADDRES3
<br />
<br />Willis A. Lemburg
<br />ISTREET OR R.F D ND CITY OR TOWN STATE llPI
<br />
<br />P.O. Box 132,
<br />
<br />Cairo, Nebraska
<br />
<br />68824
<br />
<br />
<br />21,a. METHODOFDISPOSlTION 21b. DATE
<br />
<br />21e CEMETERY OR CREMATORY NAME
<br />
<br />~ BU"81 D Removal Dee. ZO, 2001
<br />
<br />Cameron Cemeter
<br />
<br />21d CEMETERY OR CREMATORY LOCATION
<br />
<br />CITY DR TOWN
<br />
<br />STATE
<br />
<br />Apfel-Butler-Geddes
<br />
<br />D Crem~tlon D DOnation
<br />
<br />Hall County, Nebraska
<br />
<br />2211 FUNERAL HOME A[)DHE%
<br />
<br />ISTnEET OR RFD. NO.. CITY OH IOWN. S I A fe, lIPI
<br />
<br />1123 West Second,
<br />
<br />23."" . IMMEDIATE CAUSlO,
<br />P~RT ( ,
<br />
<br />(ell ~
<br />OUF TO, OR AS A CONSEQuENCE m.
<br />
<br />Grand Island, NE. 68801
<br />(ENTER OiicY-N{C;AUS[ PER LINE FORiai:lbl AND (CII--"
<br />
<br />Irltervi:l1 belwp.en onset nflfl r.i-!.~Ir
<br />
<br />(bl
<br />DI)F TO. OR AS A CONSEQuENCE DF
<br />
<br />
<br />_'____,.__~_~,~~. ~~_.~~_~____".~ '~..~__~r.."~.,,.
<br />InlefV<:I1 belween onset and (1l:~c1I~'
<br />
<br />Inte(\J<l1 between onset i~nll (j(~,111\
<br />
<br />lei
<br />PART OTHFR SIGNIFICANT CONDITIONS: ConditionS contrltllrtinglO the death but nol related
<br />
<br />"
<br />
<br />76a
<br />0 Accident 0 UMolefmlnM
<br />0 ~lJlclde 0 Pendll19
<br />D ~iOrY'lI(;lda Investigation
<br /> ?7,
<br />
<br />-.'"'''' --_.~-",~._~.
<br />2Gb. DATE OF INJURY fMo, Day, Yr.) 25c HOUR OF INJURY
<br />
<br />
<br />PART 111 IF F=!:MAL~, WAS iHE:R~ A
<br />PREGNANCY IN 1 HI: PAS 1 3 MON 1 HS'~
<br />
<br />(Ages 'O~~4.J __v~~~,,~_l~?_,.. .y'es D,..,~~o
<br />2€d D~SCRIBF HOW INJURY OCCURRF.:D
<br />
<br />
<br />
<br />26e INJURy AT WQHK
<br />Ye, D NQ D
<br />
<br />?61, 6ki~;5u?t~i~~J~{~Y it~g~r' !~rm. ~lrE!el lactory
<br />
<br />26g ! OCA TION
<br />
<br />STRE:::E:::T OR R.F n, NO
<br />
<br />CITY OR TOWN
<br />
<br />STAre
<br />
<br />27h
<br />
<br />
<br />~8a nATI: SIGNED (Mo..O;:i'y' y,)
<br />
<br />,8b TIME OF DEA TH
<br />
<br />:56
<br />
<br />4-
<br />
<br />.. r~ U!
<br />~t[,
<br />~I:=:>-
<br />"'0.., ~
<br />S if! ,. .2
<br />ua:....o
<br />~5~
<br />:=' 2; c;
<br />f...) "
<br />
<br />M
<br />
<br />;:;-:;;.
<br />~g
<br />~i ~
<br />3 g,(1
<br />]!I 0
<br />o .
<br />-.Ii'
<br />
<br />28<. PRONOUNCE=D OEAO (M{)" Day, Yr.)
<br />
<br />2Sd, PRONOUNCFD DEAD (HO/Jf)
<br />
<br />M
<br />
<br />M
<br />
<br />270
<br />
<br />__~~~_."_.'~'"W'.~.
<br />2Be. Or1lhe baSIS 01 examini::l.IIOn clJ)d'Or inve!'ihqatlon. In mv opmlon dl::!alh {JccurrOO i:l.t
<br />the time. date and place and due 10 the cause(s) stated.
<br />
<br />(SI nature ;;Ind ritle ... ISI n;;ltl,lre and Tlllel ....
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH" 30." HAS ORGAN QR TISSUE DONATION BEEN CONSIDERED'
<br />
<br />@ yeS D NO D UNKNOWN DYES _.N.:o
<br />
<br />31 NAME AND ADDRESS OF CEATrFrEf4'. (PHYSICIAN, CORONER'S PHYSICIAN OR COuNTY ATTORNEY) (Ty~e or Print)
<br />
<br />3O.b WAS CONSENT GRANTED? ~
<br />DYES -tJ. '~o
<br />
<br />Gordon Hrnicek
<br />
<br />M.D.
<br />
<br />
<br />Island, NE.
<br />
<br />68803
<br />
<br />32. REGISTRAR
<br />
<br />320 DATE FILED By REGISTRAR (Mo,. Day. Yr.)
<br />
<br />DEe 2 1
<br />
<br />.J ~.,~_.
<br />
<br />Lot Six (6) and the South Twenty Eight (28) Feet of Lot Five (5), all in Block Two (2), ill the
<br />Third Addition to Cairo, Hall County, Nebraska
<br />
<br />-'_.
<br />------------- .-.
<br />
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