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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, rr CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORQ _ON FILE WITH
<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VlTAL.STA TI8J1ItSS~CrroN.WHICH IS
<br />
<br />:TEU;:;':::::ORYFORWTAl RECORDa /~J'~
<br />5/17/2004 20070804 9 ~S8ISTAki:;kE[:E~=:
<br />LINCOLN, NEBRASKA HEAL TH JtNLJfJ!J1,JMAN SEBViCiEsift#,EM "
<br />",',':" :-~. ",~" ""',' """ ,:" :''':,~~ .Y".-' ,'~7';= ,:"
<br />
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND ~-~\7I~Es=~~~~UPPORT
<br />VITAL STATISTICS '-"- -"~ '-'-- "-=-. _.,"- 0 4 0 5 2 7 0
<br />CER TIFICA TE OF DEA Tff' ,:-ccc-= '><~". '
<br />
<br />Male
<br />
<br />
<br />IMonth, Oav, Year)
<br />
<br />,. DECEDeNT - NAMe
<br />
<br />~IRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />2. SEX
<br />
<br />Raymond George
<br />4. CriY AND STATE" OF BIRTH fllnolin US.A.. n;;lme COI){1try)
<br />
<br />Behring
<br />5~. AGE; - L.i;lst Birthday UNDER 1 YEAR
<br />(Yrs.1 50. MOS. DAYS
<br />82
<br />
<br />2004
<br />
<br />,
<br />Grand Island, Nebraska
<br />
<br />--!! 7. SOCIAL SECURTIY NUMBER
<br />
<br />.
<br />1 507-48-5905
<br />.
<br />J 8b. FACILITY - Name f/fnormstitvtion. give street and nvmberj
<br />
<br />~ Wed ewood Care Center
<br />
<br />6e. CITY, TOWN OR LOCATION OF OEATH
<br />
<br />UNDEFl1 DAY
<br />50. HOURS' MINS.
<br />
<br />February 22,
<br />
<br />1922
<br />
<br />8a. PLACE OF DEATH
<br />
<br />HOSPITAL: 0
<br />
<br />o
<br />o
<br />
<br />Inpatient
<br />
<br />OTHER
<br />
<br />[XJ NurSing Home
<br />
<br />o ReSidence
<br />
<br />D Other (SoeClfl/l
<br />
<br />ER OUlpatient
<br />
<br />DOA
<br />
<br />MIDDLE
<br />
<br />
<br />Bd. INSIDE CITY l.IMITS
<br />
<br />COUNTY OF DEATH
<br />
<br />Grand Island
<br />Sa. ReSIDeNCE - STATE
<br />
<br />Nebraska
<br />
<br />
<br />9d. STREET AND NUMBER (Including Zip Cod.; ge INSIDE CITY LIMITS
<br />
<br />68803 Yes KJ No D
<br />
<br />10. RACE - (e.g., White. Slack. American Indian.
<br />etc.l (SpecIfy)
<br />
<br />White
<br />
<br />11. ANCESTRY (e.g. Italian. Mexican. German, 81Cl
<br />ISpee'fyl
<br />
<br />NAME OF SPOUSE (If wife. gi\l8 maiden name)
<br />
<br />.II
<br />i 16. FATHER - NAME
<br />
<br />.. L'
<br />. OU1S
<br />. 16. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />(Yes. no. or unk.) (Ir yes. give waf and dates of services)
<br />No --------
<br />
<br />FIRST
<br />
<br />Roberta R. Rogan
<br />
<br />15, EDUCATION (Specify only highest grade completed)
<br />Elementary Or Secondary 10-12) College 11-1\ Or .':/""1
<br />8th Grade
<br />MIDDLE MAIDEN SURNAME
<br />
<br />oj
<br />
<br />14a. USUAL OCCUPATION (GiVl! kit'ld of work done during most
<br />of working fiffJ. even If retired)
<br />Farmer
<br />
<br />Rosa
<br />
<br />Marie
<br />
<br />Goehring
<br />
<br />Gosda
<br />
<br />19b. INFORMANT
<br />
<br />MAI~ING ADDRESS
<br />
<br />
<br />Grand Island, Nebraska 68803
<br />it 21.. MoTHDD OF DISPDSITIDN 210. DATE
<br />
<br />/1'11
<br />
<br />21e. CEMETERY OR CREMATDRY NAME
<br />
<br />IX] Burial
<br />
<br />D Aemoval
<br />
<br />Ma 11. 2004 Grand Island Cit
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN
<br />
<br />Cemetery
<br />STATE
<br />
<br />Livin ston-Sondermann F.R.
<br />220. FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO. CITY OR TOWN. STATE, ZIP)
<br />
<br />o Cremation 0 Donation
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />
<br />601 N. Webb Road
<br />23. IMMEDIATE CAUSE\~
<br />PART , .
<br />· X I lal M \A.. "::> 'I
<br />l ~UE TO, OR AS A CONSF.OUENCE OF .
<br />· $Q..V" V'L V~' \ (.N.\M fA VW'- e.'I' ~ (\..
<br />Ibl '"
<br />DUE TD. OR AS A CONSEOUENCE OF: \. _\" ,
<br />c.. 0:: \( <!.. ~ ..r w ,"-~ UJ.... ^~ 0\. "- S \t ill: I l(.
<br />lei
<br />OTHER. SIGNIFICANT CON~ITtONS - C01o~tions contributing to. the death but not'reltd
<br />P~IRT ~ ~t\J~"'" \ G)"\lV\().:it'l\l.. S'W',eX"t-.'ft. \c.oP~
<br />
<br />260. DATE OF INJURY (Mo.. Day. Yc.J 26c. HOUR OF INJURY
<br />
<br />Grand Island, Nebraska 68803-4050
<br />~~ I~~( ~~ PER LINE FOR lal.lbl. AND (ell
<br />
<br />Inte(val between onset and death
<br />
<br />k
<br />
<br />') ~ VV'(!",~j
<br />
<br />Interval between onset and cleatl1
<br />
<br />,--- 3 'i lL~
<br />
<br />27a, -OAT!:; OF D!:;ATH (Mo.. Oav, Yr.)
<br />
<br />s- ~-Q'4
<br />
<br />
<br />rntArv<.lJ belwean Onset and dei:l.tt'1
<br />-=;;,~'( .",,- '( e (),(\1
<br />
<br />26a.
<br />
<br />0 ACC:ldent 0 Undelermlned
<br />0 SUIcIde 0 Pendit'1g 26.. INJURY AT WORK
<br />0 Homicide InvestIgation vesD NoD
<br />
<br />269. LOCATION
<br />
<br />STREET OR R.F.O. NO.
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />26a. DATE SIGNED (Mo.. Day. Yr.J
<br />
<br />2Bb TIME DF DEATH
<br />
<br />... E' ~
<br />.. ~ g
<br />; i~~
<br />- 88'0
<br />- 21 ~
<br />j ~!J
<br />~
<br />
<br />..\-
<br />
<br />
<br />27c. TIME OF DEATH
<br />
<br />">-
<br />$'~ ~
<br />;,]i;l~
<br />~S:~:,..
<br />s;:;~iS
<br />1:~il
<br />~ii'o
<br />o -
<br />,~ 0
<br />
<br />M
<br />
<br />...\-
<br />
<br />27b.
<br />
<br />2Be. PRONOUNCED DEAD fMo.. D.y, YO
<br />
<br />2Bd. PRONOUNCED DEAD (HOUri
<br />
<br />M
<br />
<br />M
<br />
<br />27d. ro the best of my knowle
<br />~usetsl stated,
<br />
<br />(Si nature and Titlel ,..
<br />2S. DID rOSACCO USE CONTRIBUTE
<br />
<br />1:81' YES D NO
<br />
<br />28e. On the basis of examination and10r investigation, in my opinion death occurred at
<br />the lime, dale and place and dUB 10 the cause(s} staled.
<br />
<br />[SI nature and TlUel ..
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />X"
<br />31.~ AND A..DDRESS OF CE~rIFIER (PHYSICIAN, COFlONE.R'S PHYSICIAN OR COUNTY ATTORNEYj IType or Print)
<br />
<br />S-telJ.ef'l L 4u.
<br />32a. REGISTRAR
<br />
<br />DYES
<br />
<br />~'NO
<br />
<br />30.b WAS CONSENT GRANTED'
<br />DYES
<br />
<br />rcl NO
<br />
<br />
<br />w.
<br />
<br />fcUci I
<br />
<br />
<br />(}ral7d fsta:;?d. A/E
<br />
<br />32b. DATe FILED BY REGISTRAR (Mo.. D.y. Yc.J
<br />
<br />?SftJ3
<br />
<br />MAY 1 4 2004.
<br />
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