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<br />
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . J, /f~
<br />
<br />DATE OF ISSUANCE ~LQfI6':
<br />
<br />NOV 2 0 2007 20 0 8 0 0 313 ASSISiAty.T;fA~:'~~:J&
<br />LINCOLN, NEBRASKA HEftLTjr ~ f:!UMtt..t'~tiR~
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FIN~O SUP ::> r1. ~rl'
<br />CERTIFICATE OF DEATH :: ~: r't ..J[.; ',>.,1..
<br />2.'~Eb: :'i ' Al'H~o,i~~y, yq
<br />~r(':' '.;' ;,. November.; ~i2007"
<br />5c. Ql.ID 9""". .'~.~ , ,.' ~'Br lhlO:" Day, Yr,)
<br />HOU S 'II'J~'.'~' \ ,,,.'
<br />Qctober 1 S, 1930
<br />
<br />1. DECEDENT'S.NAME (First.
<br />Eugene Joe Budde
<br />4, CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Last,
<br />
<br />Suflix)
<br />
<br />Middlo,
<br />
<br />Sa. AGE-Last Birthday
<br />(Yrs.)
<br />
<br />
<br />Norfolk, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />77
<br />
<br />8a. PLACE OF DEATH
<br />~:
<br />
<br />o Inpallont
<br />
<br />Qll:tEB: tllI NUlling HomolLTC 0 HQsplce Fadllty
<br />
<br />507-32-7964
<br />8b. FACILlTY.NAME (II nol In&tilulion, glv~ slre~1 and number)
<br />
<br />o ER/Outpatlent
<br />
<br />o Decedent's Home
<br />
<br />~
<br />cr:
<br />is
<br />....
<br /><(
<br />ffi
<br />z
<br />~
<br />j
<br />..,
<br />Jl
<br />'E
<br />~
<br />111
<br />'lL
<br />!
<br />Ii;
<br />{l
<br />
<br />OlD\
<br />
<br />o Olher(Spedty)
<br />
<br />Western Hall County Good Samaritan Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />Wood River 68883
<br />9a. RESIDENCE-5TATE
<br />
<br />8d, COUNTY OF DEATH
<br />
<br />
<br />91, ZIP CODE
<br />
<br />99. INSIDE CITY LIMITS
<br />DYES Ij NO
<br />
<br />1lIl. COUNTY
<br />
<br />Hall
<br />
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />
<br />9283 W. One "R" Road
<br />loa. MARITAL STATUS AT TIME OF DEATH iii Married 0 Never Marned
<br />
<br />68824
<br />lOb, NAME OF SPOUSE (First. Middle, last, Suffix) II Wife, give maiden namo,
<br />
<br />o Marned, but separated 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Nadene Jo ce Peters
<br />Sulllx) 12, MOTHER'S-NAME (First,
<br />
<br />Alida Leone Burkhead
<br />
<br />Middle,
<br />
<br />Malden SUrname)
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />11. FATHER'S.NAME (First,
<br />Conrad John Budde
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Wife
<br />16c, DATE (Mo" Day, Yr, )
<br />11/16/2007
<br />
<br />13. EVER IN U,S. ARMED FORCES? Give dates of selVlce If yes. 14a, INFORMANT-NAME
<br />(Yes, no, orunk,) No
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />
<br />CITY / TOWN
<br />
<br />STATE
<br />
<br />16a,E
<br />
<br />16b, LICENSE NO.
<br />
<br />/07/
<br />
<br />IXIBul1al
<br />
<br />o Donallon
<br />
<br />o CremaUon 0 Entombment
<br />o Removal 0 Other (Specify)
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />17b, Zip Cod.
<br />68801
<br />
<br />Grand Island City Cemetery
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (street, City or Town, Stal.) .
<br />All Faiths Funeral Home, 2929 S, Locust Street, Grand Island, Nebraska
<br />
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />ee m.truction. an
<br />
<br />10. PART!. En!.r t~. r.h"'n n! even'e..d!.ease., in]'JI1.., 01 compllcallon...that dlreclly caused lhll d..th, DO NOT enl.r I.rmlnal events such as cardiac arros~
<br />re.plralo'Y arrest, olventrlculer nb~lIaUon without mOWing the ellology, DO NOT ABBREVIATE, Enter only one ca....e on a line. Add addlllonalIInosIf neces..'Y,
<br />
<br />IMMEDlATECAlJ8E(F~al
<br />dlll_ orcCIldllonmulllng
<br />Meath)
<br />
<br />
<br />onselto death
<br />
<br />on.et to death
<br />
<br />(a)
<br />
<br />r~A-
<br />
<br />.3 UM2_M.
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />
<br />(JAHJ ~~
<br />
<br />
<br />a:o .ejt.~
<br />
<br />Sequenllalty Ilet conditione, U
<br />..." _Ing \0 the c..... lI.tlCl
<br />on IIn...
<br />Enter lit UNDERLYING CAUSE
<br />(dllle_ or Injury \hilt Inltlallld
<br />the evtnllll'1HlUllng In doe")
<br />lASJ"
<br />
<br />(b)
<br />
<br />onselto death
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to dealh
<br />
<br />(d)
<br />
<br />cr:
<br />w
<br />y;
<br />Ii:
<br />w
<br />lJ
<br />i
<br />~
<br />i!i.
<br />E
<br />
<br />18, PART,~, OTHER SIGNIFICANT CONDITIONS-Condltlcns cont~buUng to the death bul not resulting In th. undorlylng cau.e given In PART I.
<br />
<br />l'rUl~~ ~
<br />
<br />20. IF FEMALE;
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />DYES 0 NO
<br />
<br />
<br />21c, WAS AN AUTOPSY PERFORMED?
<br />~
<br />
<br />21b.IF TRANSPORTATION INJURY
<br />o Dl1ver/Operator
<br />
<br />o Pa.senger
<br />
<br />o Pedestl1an
<br />
<br />o Other (SpeClty)
<br />
<br />21a, MAt'jI'lER OF DEATH
<br />lSJ.Netural 0 Homiade
<br />
<br />o YES
<br />
<br />o Not pragnant within past y.ar
<br />o Pregnant at lime of d.ath
<br />o Not pregnant, but prognant within 42 days 01 Quth
<br />o Not pregnant, but pregnanl43 days 10 1 year belore death
<br />o Unknown If pragnanl within tho pasl yoar
<br />
<br />o AccldenlO Pending Invesllgallon
<br />o Suldde 0 Could nol be determined
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />COMPLETE CAUSE OF DEATH?
<br />DYES B'NO
<br />
<br />
<br />'22C:PlACE OF ,_-'" nome;1al'l!l;'-slrael, Iactory;-officeiluttdtnll; CvI,III"cUOn ail" elc. (Gp'"11) I
<br />
<br />i3 22a. rncrE U~ INJUHT IMO.. uay, VI.)
<br />
<br />!
<br />{l 22d, INJURY AT WORK?
<br />
<br />22e, DESCRIBE HOW INJURY OCCURRED
<br />
<br />DYES 0 NO
<br />
<br />221, LOCATION OF INJURY - STREET &. NUMBER, APT, NO,
<br />
<br />CITYtro.'IN
<br />
<br />sv.TE
<br />
<br />ZIP CODE
<br />
<br />!'~
<br />i~
<br />l~~
<br />EIl.Z
<br />B goO
<br />!~
<br />e~
<br />c
<br />
<br />23a, DATE OF DEATH (Mo" Day, Yr,)
<br />November 12, 2007
<br />
<br />24e. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />z>
<br />",~!l1
<br />.1:1 2 a::
<br />i~g
<br />liE!;(:!:i
<br />E ."'/= Z
<br />llffizo
<br />..z::>
<br />.1:100
<br />~~o
<br />8Ci
<br />
<br />m
<br />
<br />
<br />23c, TIME OF DEATH
<br />04:40 a m
<br />
<br />24c, PRONOUNCED DEAD (Mo" Day, Yr,) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e, On the basis of exerrinaUon snd/orlnvesllgatlon, In my opinion death occurred at
<br />Iho bme, dale and plsce snd due 10 tho cauu(S) stated. (Signature and Till. ) T
<br />
<br />26a. HAS ORGAN OR TISSUE DC)"'ATION BEEN CONSIDERED?
<br />
<br />~S 0 NO 0 PROBABLY 0 UNKNOWN 0 YES ~NO
<br />?7, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Pnnt)
<br />John A Wa oner MD 800 Al ha Grand ISl
<br />
<br />29a, REGISTRAR'S SIGNATURE
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />~
<br />
<br />Nol Applicable It 26a I. NO 0 YES
<br />
<br />
<br />28b, DATE FILED BY REGISTRAR (Mo., Day, Yr,)
<br />
<br />NOV t 4 2007
<br />
<br />
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