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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUlilANc~RVlCES
<br />SYSTEM, "CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FiLE-WiTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS !lECtION;WHlCfflS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~~-~i~ ..:C'.. ... - -I: 7r ~.c~-~,_~-\~
<br />
<br />DATE OF ISSUANCE 48.' .. -,tj~.-, ~ ~-=, ',~
<br />JUN 262002 2007070:-~ A1UyAlCQDPER~
<br />ASSI$tA*t STA TE Ri(jIST!lKR~~
<br />HEAL TH AND H~AN'$~9f.~~'(8TE~c
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVKES-fINANCEA-Nb $t1PP()RT
<br />VITAL STATISTICS --- -
<br />CERTIFICATE OF DEATH
<br />
<br />Exhibit "A"
<br />..... .. n. ,..._., ..
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />()!:-C~!)ENT-NAME
<br />
<br />foll.t..; J ly~iI){)l F
<br />
<br />LAST
<br />
<br />2 SEX
<br />
<br />Albert
<br />
<br />Male
<br />
<br />Henry
<br />
<br />Werner
<br />
<br />I, CITy AND STATE OF RIRTH --:-ii-;,o;'" USA. ".1/"0 count'vl
<br />
<br />UNDER' i"YEAR
<br />50 MOt";: DAYS
<br />I
<br />_ on _.__1.._ ._..__ ._',.~
<br />8a PLACE or DEA II ~
<br />
<br />t>a AGC.. Lasl Birthday
<br />
<br />UNDER' DAy
<br />5c. HOUI1S MINS
<br />
<br />. Grand Island, Nebraska
<br />
<br />(Vrs I
<br />71
<br />
<br />~'.'-'.'.'-"_..
<br />. 7 SOl-tAl" SE"CURlIY NUMB!:: 1-1
<br />i .
<br />I
<br />~ BD r ACILlTY .. Name
<br />
<br />I
<br />I
<br />
<br />506-28-8574
<br />
<br />HOSPITAL 0 Inpallent OlHEH
<br /> 0 F.R Outpatient
<br /> 0 DOA
<br />
<br />(ff I/m In.',!duf!u"', give :;tmef dnd 'lumber,!
<br />
<br />1705 Ando Street
<br />
<br />
<br />Bt CIIV lOWN OR LOCATION OF DEATH
<br />
<br />8e COUNTY or DEATH
<br />
<br />9<1. RE:SIOENCE - STATE
<br />
<br />Grand Island
<br />
<br />.. -or 9b COUNTY
<br />
<br />9c
<br />
<br />02
<br />
<br />07266
<br />
<br />-roo,
<br />: J CIA fC Of- DEATH :M{'l1fh nil ~'-~.-1'!
<br />
<br />
<br />June 16, 2002
<br />6 OATF OF BIRTH rMo;;h~671,~::' Y~~afj
<br />
<br />Deeemb~!"_Jl,J93l!.__
<br />
<br />o
<br />[Xl
<br />o
<br />
<br />Nursing rio!!I!:,
<br />
<br />Re~ld!:!m:f!
<br />
<br />01hef iSoe.:i/\
<br />
<br />Hall
<br />
<br />Hall
<br />
<br />-".,,--"-'_..,,--"-,._-------~.- '..'-.-------:..-
<br />'3TRt;ET AND NUMBER ffnc.'t...~if)t)Z/P CodtEJ! i 0e Ir~SIDE CITy UMI"i S
<br />
<br />1705 Ando Street ___~_ Ye, [!I No D
<br />D WIDOWED '3 NAME OF SPOlJSI: ,If wile qrl1e m<~Jdt"?n name)
<br />DIVORCED Connie Dubas
<br />
<br />Nebraska
<br />
<br />
<br />American
<br />
<br />, 0 RA~re4.. WhilE;! RI<:Ick Arnp.p(:nn Indian
<br />E;!tc ~ fSoeclfYI
<br />
<br />11 ANCESTRY Ie g Itolian, Mexican. German, olel
<br />(Spec11vl
<br />
<br />White
<br />
<br />J
<br />
<br />14a USUAL OCCUPA TlON {Give kmd of worA' done dvring most
<br />of working life. even if reflrl?(1!
<br />
<br />Paint Contracting
<br />
<br />14b
<br />
<br />i 16FIiTHER- NAM~~~""^-FIRS1--------;;;;OOCr
<br />
<br />17 MOTHER
<br />
<br />15 FOUCAT}g:i.JE.~:.I,~Y..o(lly highest grad'.:.' cClfl1pleledl
<br />Elementary or SeCOf)dary 10.12) C!)Ueqe 11.4 or ~. I
<br />12 1-
<br />
<br />MAIDEN SURNAME
<br />
<br />Painter
<br />
<br />l.AST
<br />
<br />MIDDLE
<br />
<br />Albert VVerner
<br />= 18 WAS DE:.C~ASE.O EVI:.H IN U,$ ARMED FORCES? _._...-'-.'.._.-..-...--~9;;'iNFORMANl - NAMe
<br />IYeN~ 0' unk.J L II/ y., u". wa< and date, of ,"'''ces~_ ~
<br />
<br />190. INfCORMANT MAILING ADORES5 iS1Ht.t:l OR A.F.u, NO" CITY OR TOWN STATF ZIP)
<br />
<br />Connie Werner
<br />
<br />Helen Schmitz
<br />
<br />1705 Ando Street, Grand Island, Nebraska 68803
<br />
<br />
<br />21<1., MEtHOoOF DISPOSITION ?lh, DATF
<br />
<br />00 Burial
<br />
<br />DROII'loval
<br />
<br />June 19,2002 Grand Island City Cemetery
<br />21d CEME~TERY OR CREMATORY LOCATION CI1'y ;:)~-----------sTAT~-
<br />
<br />#1071
<br />
<br />All Faiths Funeral Home
<br />
<br />o CremallQl1 0 l)onatlQf"
<br />
<br />21c C[M-[Y~HY"OR 6~F.MATOFW NAMF
<br />
<br />Grand Island, Nebraska
<br />
<br />220 F\JNERAl HOME ADDRESS
<br />
<br />ISTREET OR RFo. NO CITY on TOWN. STATE^ ZIPI
<br />
<br />2929 South Locust Street, Grand Island, Nebraska 68801
<br />
<br />23 IMMEDIATE CAUSF
<br />PART
<br />I
<br />
<br />IFNTFR ONLY ONE CAUSE PER LINE FOR lal.lbl. AND lCIl Interv.31 between onset dr'I() (K',111
<br />
<br />."____llp-ls,IlOwn ...
<br />Jnlerv<:Il between onset and (jp.;lHl
<br />
<br />Natural
<br />
<br />causes
<br />
<br />(<:I)
<br />DuE'ro. QR AS A CONSEQUENCE or
<br />
<br />',_...... 101
<br />....'.-.D-ut i (\'-OR AS A CONSFOUF.NCE OF
<br />
<br />In1erval hetwl:!f:!'n onf,el "nl1 nf!;W'
<br />
<br />lei
<br />PART OTHFR SIGNIFICANT CONo'ITI6N~; --C;;y.i~'O;;$..C(~~b~i';'~';q-;() lh€ d/;!;:I.lh but not rel(lleo
<br />
<br />1/
<br />
<br />
<br />26;) I Xib rMTE or INJURy /M~!,O~-; Yr.}
<br />
<br />~n AwOOnl [J u""",,,,,,,,,,,,,, i
<br />
<br />o S\Jlcll1e Ll f)') Iii (Iii r 260 JNJURY AT WORK
<br />
<br />o Hom'"de __:'~~::J Ya, D No D
<br />
<br />127<:\ DA Te OF DCA I H (M{) Uny, Yr.J
<br />
<br />2Gc. HOUR OF IN.HJRY
<br />
<br />28q, LOCATION
<br />
<br />-~_....
<br />
<br />24 AlJ.~r(ipsy -FS W^'=, CASE rlEFERRED TO MEDICAl
<br />[XAMIN[H uH COHONE:.H 1
<br />No [XL Yes KJ _ill_ _
<br />
<br />STREFT OR R F I) NO
<br />
<br />STAlL
<br />
<br />---_.__._-'-'-'~
<br />28<:1 OATf.: SIGNED (Mo [Mv, Yr'1
<br />
<br />.._. (Sy ~ Lj - t' ?--
<br />
<br />i.",7"
<br />i ~ g ?7b OA TE SIGNED IMo, O.=ty, Yr.J
<br />. <.""1. i ~
<br />. E I), :i':
<br />.. 8 g>o
<br />i ~ ~
<br />J
<br />____L,,_,l?..!Z1~~,~re a~d Title) ... ~
<br />29 DID roSACCQ USe CONTRIBUTe TO THr DEATH' -~N OR TISSuC DONATION BEEN CONSIDFRED'
<br />D yes D NO Qg UNKNOW~..^..___.._, DYES Qg NO
<br />31 N^ME ANO A6DR'~SS(; CFRTlFlER (PHYSICIAN, CORONER'S PHYSICIAN Of-l"COUNTYATTORNEYi rTvoe or Print)
<br />Sgt D Vitera, GIPD, 131 S
<br />
<br />-----1 n,
<br />
<br />~. rI, IJ,I
<br />
<br />H~i
<br />~ ~ ~
<br />~~fl
<br />0:_
<br />1..:1 ,>
<br />
<br />J U1}_~___J6)_) 002
<br />
<br />28e, On Hle h<3sis of e~amln<3110n <3nd Of investIgation. in my Oplf\lorl (je<lU~ O(~(:urred 011
<br />the IHl'l(', dale i:l.nd pl8.(;e ' W due 10 the c- U!if;!(!;) sti;lled
<br />
<br />___~ 3 5__~~
<br />
<br />TIME OF DEATH
<br />
<br />28c PRONOUNCED DEAD !Mo Day, Yr.l
<br />
<br />M
<br />
<br />27d T (J the be:;I!)! my knowledge, death OCCufreCI al1l1e lime dnle Clnd pl<:\ce and due to the
<br />callscl~i Slated.
<br />
<br />II v Ok TOWN
<br />
<br />]2B';--IiMC OF DEA TH--
<br />
<br />._9_:.Q_Q_._?:ID
<br />2Bd. f-lHONOlJNU-l) DEAD (Houri
<br />
<br />
<br />32a REGISTRAR
<br />
<br />Locust '_J;rand
<br />
<br />~/I ;J ~t1-
<br />
<br />I 32t,
<br />
<br />__Juu_
<br />
<br />JUN 2 5 2002
<br />
<br />Is land,
<br />
<br />NE
<br />
<br />.KJ NO
<br />
<br />68801
<br />
<br />DATE FILED ~B~;:'RA'r'l fM(l nay Yr)
<br />
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