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r R STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REWRD:DNFILEAVITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS *ECT10N,-WHWH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. _ DATE OF ISSUANCE �y�y- AuG 3 0 2006 200706399 /LiI'YLEr. cvoPAA ASSI�'!ANT;STATE REGISmAR- LINCOLN, NEBRASKA HEALTMANU -NUMAN SERVICES , STATE OF NEBRASKA -- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE, AND SUPPORT OF DEATH 06 274' 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.) Jerome William Niedfelt _ Male June 26, 2006 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 6a. AGE - Lest Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) (Yrs.) MOS. DAYS HOURS MINS. Grand Island, Nebraska 79 November 8, 1926 7. SOCIAL SECURITY NUMBER 506 --28-7211 8b. FACILITY-NAME (If not Institution, give street and number) Tri-- County Hospital 8a. PLACE OF DEATH HOSPITAL: M Inpatient OTHER: U Nursing Home /LTC ❑ Hospice Facility ❑ ERlOutpatient U Decedent's Home ❑ D04 U Other (Specify)- ..... --- ......_ Sc, CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH Lexington 68850 Dawson 9a. RESIDENCE•STATE 91b. COUNTY 9c. CITY OR TOWN Nebraska Hall Grand Island 9d. STREETAND NUMBER 9e. APT. NO 9f. ZIP CODE 1515 West Hwy 34 68801 10a. MARITAL STATUS AT TIME OF DEATH Z Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) It wife, give maiden name. 9g. INSIDE CITY LIMITS ❑ YES C1 NO ❑ Married, but separated LJWidowed C3 Divorced ❑Unknown Doralene Schade 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname) _ William - Niedfelt Irma Roby 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. 14a. INFORMANT -NAME 14b. RELATIONSHIP TO DECEDENT (Ye ulunk) 1944 -1946 Doralene Niedfelt Wife NI Burial L] Donation f MegLMER•SIGNATURE (� Lv - 16b -LTC LICENSE 001 June ( 29, y Y 15. METHOD OF DISPOSITION 16a J' Y r ) 2006 U Cremation ❑ Entombment 16d. C13611TERY, CREMATORY OR OTHER LOCATION CITY! TOWN STATE C1 Removal ❑ Other (Specify) Grand Island City Cemetery, Grand Island, Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 171h. Zip Code All Faiths Funeral Home,2929 S. Locust St.,Grand Island, NE 68801 18. PART I. Enter the chain of events -- diseases, Injuries, or complications - -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final (a) rte ✓ .a A.1, 7 <1 // y disease orconditlonresulting DUE TO, OR AS A CONSEQUENCE OF: In death) Sequentially list conditions, If (b) / `L r r -A C' , "Q, )) v r any, lead Ing to the cause listed ---- --_- ....._NCE DUE T0, OR AS ACONSEQUENCE OF: on line B. Enterthe UNDERLYING CAUSE (disease or Injury that Initiated (c) the events resulting In death) DUE TO, OR AS A CONSEQUENCE OR LAST (d) ' APPROXIMATE INTERVAL I I onset to death I I I I onseltodeath I I onset to death I I onsettodealh I 18. PART 11. OTHER SIGNIFICANT CONDITIONS. Conditions contributing to the death but not resulting In the underlying cause given in PART I. 19, WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES FX NO 20. IF FEMALE: 21a. MANNER OF DEATH 21b, IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? ❑ Not pregnant within past year ❑ Natural ❑ Homicide ❑ Driver/Operator ❑Pregnant at time of death U Accident❑ Pending Investigation ❑Passenger U YES MIND El Not pregnant, but pregnant within 42 days of death U Suicide ❑ El PedestrianCould not be determined 21d. WERE AUTOPSY FINDINGS AVAILABLE TO U Not pregnant, but pregnant 43 days to 1 year before death U Other (Specify) COMPLETE CAUSE OF DEATH? ❑ Unknown If pregnant within the past year . ❑ YES M NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b, TIME OF INJURY 221. PLACE OF INJURYAt home, farm, street, factory, office building, construction site, etc. (Specify) m 22d. INJURYATWORK? 22e. DESCRIBE HOW INJURY OCCURRED ❑ YES ❑ NO 221, LOCATION OF INJURY S.. - - _ - TREET 8 NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE to ILU 25.01DT013A000 USE CONTRIBUTE TO THEDEAATHHI 26a. HAS ORGAN OR TIS$UEDONATION BEEN CONSIDERED? Cl YES ❑ NO Q PROBABLY t;Q UNKNOWN ❑ YES ZrONN_O 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Mark Jones, M.D. PO Box 797 Lexington, Nebraska 28a. REGISTRAR'S SIGNATURE 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES 68850 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) 'JUL 5 2006 23a, DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIM E OF DEATH H June 26, 2006 az m 4 � .._- .....__....... ..._ 23b. DATE SIGNED (Mo., Day, Yr.) �'r ° � .... -- 23c. TIME OF DEATH ..._ N Q � >- - ..... 24c. PRONOUNCED DEAD (Mo., Day, Yr.) . 24d. TIME PRONOUNCED DEAD � 06 3 11:10 a. m cc ITl M 23d. To the best of my knowledge, death occurred at the time, date and place W 24e. On the basis of examination and /or Investigation, In my opinion death occurred at Q and due to the cause(s) stated. (Signature and Tllle ) v p p the time, date and place and due to the cause(s) stated. (Signature and Title) V to ILU 25.01DT013A000 USE CONTRIBUTE TO THEDEAATHHI 26a. HAS ORGAN OR TIS$UEDONATION BEEN CONSIDERED? Cl YES ❑ NO Q PROBABLY t;Q UNKNOWN ❑ YES ZrONN_O 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Mark Jones, M.D. PO Box 797 Lexington, Nebraska 28a. REGISTRAR'S SIGNATURE 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES 68850 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) 'JUL 5 2006