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<br />
<br />
<br />
<br />--LOt Twenty-Six (26),
<br />City of Grand Island,
<br />
<br />in Hidden Lakes Subdivision Number Four
<br />Hall County, Nebraska
<br />
<br />(4),in the
<br />
<br />5.50
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMAN SERVICES
<br />SYSTEM, "CERTIFIES THE BELOW TO .BE A TRUE COpy OF THE ORIGINAL RE.CJJJ!lJ:L-QN:PU WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL sTAnsJ1f:i'u~~H IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . ':;""'-...fC?~~.
<br />
<br />DA TE OF ISSUANCE ::0 .,. , "':J;OO:~
<br />J U N 9 2003 2 0 0 8 0 2 1 7 3 -/~riWf
<br />LINCOLN, NEBRASKA 'SfIJJf~
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND
<br />VITAL STATISTICS
<br />CERTIFICA TE OF DEA
<br />
<br />
<br />York. Nebraska
<br />7. SOCIAL SECURTIY NUMBER
<br />
<br />UNDER 1 YEAR
<br />5b. MOS, I DAYS
<br />I
<br />
<br />
<br />(Maf)/n. Day. Y88r)
<br />
<br />
<br />1, DECEDENT - NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />505-64-2135
<br />
<br />
<br />2003
<br />(Month. Day. Year)
<br />
<br />Nahc
<br />4, CITY AND STATE OF BIRTH /II nol In U.s.A.. namB country)
<br />
<br />1947
<br />
<br />8b. FACILity - Nama
<br />
<br />(If not institution, give St~8t and number)
<br />
<br />[K] Inpatlent
<br />
<br />o ER Outpatient
<br />o DOA
<br />
<br />~.~:
<br />
<br />D NurSing Home
<br />0 ResIdence
<br />0 Other (Speclf,(1
<br />
<br />Br anLGH Medical Center West
<br />Bc. CITY. TOwN OR LOCATION OF DEATH
<br />
<br />
<br />Nebraska
<br />
<br />
<br />(fncluoing Zip Cad81
<br />
<br />9.. INSIDE CITY LIMITS
<br />
<br />Lincoln
<br />9a. RESIDENCE - STATE
<br />
<br />11. ANcesrRV le.g.. Italian, Mexic:an, German. etcl
<br />elN ISpeclfy) ISpBCl1y!
<br />white American
<br />14a. USUAL OCCUPATION /Give kind at work done during most 140. KIND OF BUSINESS INDuSTRY
<br />of working tim. even if retired)
<br />Co-Owner Office Mana er
<br />16, FATHER - NAME FIRST MIDDLE
<br />
<br />Yes [}Q No 0
<br />13. NAME OF SPOUSE (llwiI8. give maiden name)
<br />
<br />
<br />Ronald Emken
<br />
<br />15. EDUCAtiON (Specify only highes1grade completed)
<br />Elementary or Secondary (0-12) COIl~e (1-4 or S"I
<br />
<br />MIDDLE MAIDEN SURNAME
<br />
<br />Alverdo Preston
<br />
<br />18, WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />(Ye&. 110. or unk.1 [If yes. give war and dates 01 services)
<br />
<br />Vir inia
<br />
<br />Alene
<br />
<br />Burne
<br />
<br />
<br />Ronald Emken
<br />
<br />MAILING ADORESS
<br />
<br />ISTREET OR R.F.D, NO" CITY OR TOWN. STATE. ZIPI
<br />
<br />
<br />4413
<br />LICENSE NO.
<br />
<br />
<br />68801
<br />21 c. CEMETERY OR CREMATORY NAME
<br />
<br />,'''-
<br />
<br />IX] Buriel 0 Removal J ne 5 2003 Pl a i nvi ew Cemeter
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN
<br />
<br />STATE
<br />
<br />L ivinQston.Sondfrmann FuneralHH QCt.mallon o Dona"on
<br />22b. FUNERAL HOM~ ADDRES~-' ISTREET OR R.F,D, NO.. CITY OR TOWN, STATE. ZIP)
<br />
<br />Bradshaw Nebraska
<br />
<br />601 North Webb Road. Grand Islarld~ Nebraska 68803
<br />23. IMMEDIATE CAUSE IENTER ONLY ONE CAUSE PER LINE FOR lal. Ib). AND lell
<br />PART
<br />I lal Si..\. b Cl('<lc k 1\-0, G( ^"'W\.
<br />DUE TO, OR AS A CONSEQUENCE OF
<br />
<br />26a.
<br />
<br />2tlb. DATE OF INJURY IMo.. Day. Yr,) 26e. HOUR OF INJURY
<br />
<br />
<br />M
<br />26f. b~;5u~~iA~J~~.Y (b~W" fatm, street. factory
<br />
<br />
<br />I Interval between Onset and death
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I Interval between onset and death
<br />I
<br />I
<br />I
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />
<br />
<br />
<br />Ibl
<br />DUE TO, OR AS A CONSEQUENC~ OF,
<br />
<br />lei
<br />F'ART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related
<br />
<br />II
<br />
<br />o Accident 0 Undetermined
<br />o Suicide 0 I'ending 2618. INJURY AT WORK
<br />o HOmiCide Inve5tigation Yes O. No 0
<br />
<br />269. LOCATION
<br />
<br />STREET OR R.F.D. NO.
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />27a. DAT~ OF DEATH IMo" Day. Yr.)
<br />
<br />28., DATE SIGNED IMo" Dsy. Yr.)
<br />
<br />28b. TIM" OF OEATH
<br />
<br />
<br />9:0Qa
<br />
<br />di
<br />lI~)-
<br />8;:;~~
<br />.!!~~
<br />~~(.)
<br />8 "
<br />
<br />M
<br />
<br />E:::
<br />j~ '"
<br />t..",
<br />'" ~o
<br />1l~
<br />~~
<br />
<br />27e. TIME OF DEATH
<br />
<br />28e, PRONOUNCED DEAD (Mo.. Day. Ycl
<br />
<br />28d. PRONOUNCED DEAD {Houri
<br />
<br />M
<br />
<br />2Be. On the basis ofexarninalion and'or investigation. in my opinion death occurred at
<br />the time. date and place and due 10 Ihe causefsjstated.
<br />
<br />30.b WAS CONSENT GRANTED'
<br />IKJ YES 0 NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONE ATTORNEY I (Type or Prinl) 68506
<br />Scott Heasty, M.D. Inpatient Medicine Services 4433 S. 70th, Suite 100. Lincoln, N
<br />32.. REGISTRAR 32b. DATE FILED BY REGISTRAR IMo.. Day. Yr,)
<br />
<br />
<br />JUN
<br />
<br />6 2003
<br />
|