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<br />STATE OF NEBRASKA """',,
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ~tJP}JYl1-~,IJ\Sft'JVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE O,!!!J~~!!!!.~clf"H ",.
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITALST~~'~lJf!-'!if~fH fS[ Doralene Niedfelt
<br />J}:'~_~E...qAL. EEPOS~TC?J!'(,fQ,! VIT~!:. REC9..RDS:.,-----"___,..,{.....""'~,', .,',,"', "., -'0 ""':;':,''',JJ.' '~"', ',,'~,',' ''','';~..o=, ,',.i::-=., ",',' "t,:...1 ~1 S W U.S.
<br /> Hwy. 34
<br />. .- - "- ,-- " - " .., -"'~---~-----' "'- "-"" ", , i.'" .-' ~'w:d ,~~- ,oraiia Isfiiit3;-NE 68801
<br />DATE OF ISSUANCE , _ _' ~' _" '" '="' ',:" ~-- : ,',._ '
<br />~:': , r.4l1LEY8. COOPER l:.-_., " .- - --
<br />AUG 3 0 2006 ' AsSISTANT STATERE..h.i.StllAR
<br />HE'ALrif-AND,HU!IlANSERVicES
<br />~_" f"'~~:IP!,c'" . c,'"
<br />--r~ ,~..-: - ., .- .
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />200802506
<br />
<br />~
<br />
<br />
<br />~:',
<br />
<br />STATE OF",N, E" BRASKA - DEPARTMENT, ,O,F, HEALTH AND H, UMAN SERVICES FINANCE}\ND SUP, POR,T"I1"'I! If:' " 11);, '",f" '41' 2',
<br />. , CEFlTIFICATE OF DEATH____ILUJL_L l' " ;,
<br />1. DECEDENT'S.NAME (First, Middlo, Last, Suffix) 2, SEX 3, DATE OF DEATH (Mo" Day, Yr,)
<br />Jerome William Niedfelt Male June 26. 2006
<br />
<br />4, CITY AND STATE OR T~RRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Grand Island, Nebraska
<br />
<br />60, A(J~.La,t Birlhday
<br />(Yrs,) 79
<br />
<br />5b, UNDER 1 YEAR
<br />MOS, DAYS
<br />
<br />50, UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />6. DATE OF BIRTH (Mo" Day, Yr,)
<br />
<br />November 8, 1926
<br />
<br />7. SOCIAL SECURITY NUMBER :3a PLACE OF D~ATH
<br />506-28-7211 ~~
<br />"' ~c^''' '" '^" (" ""' ,,,.m",,"". "'"' ",.., '"' ",.." ( ~ -
<br />
<br />Tri-County Hospital
<br />
<br />- -
<br />6c, CiTY OR TOWN OF DEATH (Include Zip Codo)
<br />Lexington 68850
<br />
<br />-. ---. I 9b, COUNTY
<br />.__1 Hall---.
<br />
<br />Xl Inpatienl
<br />
<br />QlliEB: W Nursing Home/LTC 0 Ho'pico Faci'ity
<br />
<br />o ER/Oulpatient
<br />
<br />o Decedent's Home
<br />
<br />W rx::YI 0 Olher (Spocily)
<br />
<br />r.. ..d. '.. C..O. U...NTY OF DEATI.;.-.-
<br />
<br />Dawson
<br />
<br />ta Married IJ Never Married 10b. NAME OF SPOUSE (Fir"" Middle, La51, SUffix) If wifo, givo maiden nam..
<br />
<br />
<br />9f, ZIP CODE
<br />68801
<br />
<br />9g. INSIDE CITY LIMITS
<br />U YES Q[ NO
<br />
<br />34
<br />
<br />IJ Morried, but s.paral.d IJ Widow.d IJ Dlvorcod IJ Unknown Dor a I ene Schade
<br />
<br />11, FATHER'S-NAME (Firsl,
<br />William
<br />
<br />Middle,
<br />
<br />Last.
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S.NAME (First,
<br />Irma
<br />
<br />Mlddi.,
<br />
<br />Maid.n Surnam.)
<br />Roby
<br />
<br />Niedfelt
<br />
<br />13, EVER IN U,S, ARMED FORCES? Giva dat.s ol..rvice If yes, 14a.INFORMANT"NAME
<br />(Yolnff,t;unk,) 1944-1946 Doralene
<br />15, METHOD OF DISPOSITION 16a'fMBALMER-SIGNI\;URE ~ fl.. ) ,
<br />
<br />~ :~~:~tion ~ ::::::onl ;6d~~;d~~~M~RYOR ~THER :~~~,v
<br />
<br />UR.moval o Othor(Spocily) Grand Island City Cemetery,
<br />
<br />Niedfelt
<br />
<br />I 16b, L1CII~E;~ 1
<br />
<br />CITY / TOWN
<br />Grand Island,
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />160, DATE (Mo" Day, Yr, )
<br />June 29 2006
<br />
<br />STATE
<br />Nebraska
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreel, Cily or Town, Slata)
<br />All Faiths Funeral Home,2929 S.
<br />
<br />17b, Zip Code
<br />
<br />68801
<br />
<br />PART-'f"'Enier Ihel::.b_~I;IDD.""dis9ases, injurIes, or complicalionsuthal directly caused the death. DO NOT enter terminal events such as cardiac arresl,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a tine, Add addl1lonalllnes If necessary.
<br />IMMEDiA.T~ CAUSE:
<br />
<br />QnRel1n rteath
<br />
<br />IMM~DlATE CAUSE (Final
<br />disease or condition resulting
<br />In de.th)
<br />
<br />(a)
<br />
<br />fcy /i~:-:, /b.l'"{
<br />
<br />q V' ~::l~
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset 10 dealh
<br />
<br />S.quenllally 1191 condilions, if (b) I '1, t r""l '- .... v"" -<;0. )) V """ 1
<br />
<br />any, leading 10 Ihe cau.e lI.ted DUE TO, OR AS A CONSEQUENCE OF.:"
<br />on line 8.
<br />~nlerthe UNDERLYING CAUS~
<br />(dl..... or Injury 'ha'lnlllaled (c)
<br />the events r4:!.Bultlng In death)
<br />lAST
<br />
<br />!J }~'-d
<br />
<br />onset to deafh
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />! onset to death
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Condition. contributing to tho d.ath but not re.ulling in Ihe und.rlylng c.us. glv.n In PART I,
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />U YES o;;r"NO
<br />
<br />20, IF FEMALE:
<br />o Not prognanl within past year
<br />U Pregnant at time of death
<br />Cl NOI pr.gnanl, but preQnant within 42 day' of d.ath
<br />
<br />21a. MANNER OF DEATH
<br />o Nalural 0 Homicido
<br />
<br />21b.IFTRANSPORTATION INJURY 210, WAS AN AUTOPSY PERFORMED?
<br />U Drlv.r/Op.rator
<br />
<br />o AccidentO Pending Invesllgatlon
<br />
<br />o Passenger
<br />o Pedestrian
<br />
<br />DYES
<br />
<br />!XI NO
<br />
<br />\
<br />
<br />o Suicide 0 Could nol b. det.rmln.d
<br />
<br />U Oth.r (Sp.Clfy)
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES Xl NO
<br />
<br />o NOI pregnant, but pregnant 43 days 10 1 year before death
<br />o Unknown if pr.gnant within Iha pasl year
<br />22a, DAT~ OF';NJUAYIMo~, Yr,) __ I 22b, TIME OF INJURY-
<br />- 1..." m
<br />
<br />22c, PLACE OF INJURY-AI home, farm, stroot, factory, oflice building, construction sit., .Ie, (Specify)
<br />
<br />o YES 0 NO
<br />
<br />
<br />22e, DESCRIBE HOW INJURY OCCURRED
<br />
<br />22d.INJURY ATWORK?
<br />
<br />221, LOCATION OF INJURY - STREET & NUMBER, APT NO.
<br />
<br />CITYlrOWN
<br />
<br />STIIJ'E
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo.. Day, Yr,)
<br />June 26, 2006
<br />23b. DATE ?IG~EP (Mo., Day, Yr,)
<br />6r' 3 "'10 f...
<br />
<br />24a. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />23c, TIME OF DEATH
<br />11:10 a. m
<br />
<br />~::i~
<br />.cd3 z
<br />lliiigj
<br />]H
<br />c..a..-:c::;
<br />Ii." ~~
<br />uf5z
<br />llZ=>
<br />00
<br />~a:(J
<br />811
<br />
<br />m
<br />
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d, To Ihe besl of my knowl.dgo, death occurr.d at Ih. time, dale and placo
<br />and dU.lo the cau,ef') 'taled, (Signalur. andTlllo)",
<br />
<br />7/0 ~1 ...,
<br />
<br />24e. On the basis 01 examlnallon and/or InvBstigation, in my opinion death occurred al
<br />the lime, date and place and due 10 Ihe cause(s) atated, (Signature and TItre) T
<br />
<br />
<br />25. DID TOBACCO USE CONTRlaUTETOTHE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />
<br />DYES IJ NO _0 PROBABLY ~,,!!,!:!OWN 0 YES __. ~'_.... .__ Not Appllcabl. if 26a Is NO 0 YES ,fl-NO
<br />21, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ. or Print)
<br />Mark Jones, M.D. PO Box 797 Lexington, Nebraska 68850
<br />
<br />2Ba. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr,)
<br />
<br />
<br />'JUL
<br />
<br />I) 2006
<br />
<br />\ Lot~ rcr;-Blcock 2 of Roush S
<br />
<br />_ill-the City of Grand Island, Hall County, NE
<br />
<br />._~=,~.
<br />
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