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<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF ElIRTH
<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA H~ALT, ~/tI.fJNA,tJ SERVICES
<br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGt ~ fji~RDiJQ/tFIt..~ WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL/S ~Ct~N,~t':JH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ;?n'~ <;).....~ p..-r, ~~ d J;
<br />
<br />DATE OF ISSUANCE -1. ..11- 'I. ~ ((:l ~
<br />MAR 042008 200802695 ~ i.$IS~ ~~~;;~
<br />~r"SA f. TH AND HI.1WNSEFf/..I1;EB,'
<br />";,, ~~. ,',' . !"ij il(il
<br />STATE OF NEBRAS~.:.~~~RTMENT OF HEALTH AND HUMANilEf&~J:~,Qo"""","~';~~....:Jj.')
<br />L;~t( IIFICATE OF --~.1 .....-<'.. ";<elCllf\~~~;l)
<br />1.DECEDENT'S-NAME (Flret Middle, Llet, Suffix) 2. SEX . ;'.' -. '. /'. .3,p~E.OF DSATH..Day,Yr.)
<br />I;,'a ~ . I Uj..Y \ ,_
<br />Max Paul Kunze Male ~.:_ /i"ab~uary22, 2008
<br />al. AGE-Laat EllrthdlY ab. UNDER 1 YEAR lie. UNDER 1 DAY a. DATE OF ElIRTH (Mo., DIY, Yr.)
<br />HOURS I MIN8.
<br />
<br />I September 2,1919
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />\
<br />
<br />(Yre.)
<br />
<br />MOS.
<br />
<br />DAYS
<br />
<br />Howard County, Nebraska
<br />
<br />7. SOCIAL SECURITY NUMElER
<br />
<br />88
<br />
<br />~
<br />(0
<br />....
<br />i
<br />I
<br />;
<br />UJ
<br />Z
<br />:J
<br />Il.
<br />
<br />519c18..5875
<br />
<br />al. PLACE OF DEATH
<br />Il2m!lIAI.; 0 Inplllent
<br />D ERlOutpotlent
<br />DDOA
<br />
<br />~O Nurelng HomAlL TC
<br />iii Oecedenr. Home
<br />o Other(Speelfy)
<br />
<br />o Hoaplee Flelllty
<br />
<br />8b. FACILITY -NAME (If not Instltutlon, give atreat and number)
<br />
<br />1204 Kennedy Drive
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip COds)
<br />Grand Island 68803
<br />
<br />lad. COUNTY OF DEATH
<br />Hall
<br />
<br />~
<br />'tl
<br />G>
<br />!E
<br />~
<br />!
<br />is.
<br />8
<br />u
<br />G>
<br />co
<br />o
<br />...
<br />
<br />~a. RESIDENCE-8TATE 19b. COUNTY 18e. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />8d. STREET AND NUMBER 98. APT. NO. /91, ZIP CODE
<br />1204 Kennedy Drive 68803
<br />101. MARITAL STATUS AT TIME OF DEATH iii Mlrrled 0 Never Mlrrled/ lab. NAME OF SPOUSE (Flret Middle, Laat, Sumx) II wile, give mslden nlme.
<br />o Mlrrled, but seporlted D Widowed D Divorced 0 Unknown I Fern M Silk
<br />
<br />11. FATHER'S-NAME (FiBt, Middle, L....t, Suffix) 112. MOTHER'S-NAME (FIBt, Middle, Malden Sumlme)
<br />Paul Kunze Ida Clara Warmer
<br />13. EVER IN U,S. ARMED FORCES? Give datea ohervlee II Yes. I 14a.INFORMANT-NAME
<br />(Yes, No, or Unk.) YBS 06/03/1941..09/17/1945 I Fern M Kunze
<br />1&. METHOD OF DISPOSITION 160.EMBALMER-8IGNATURE
<br />(ilBurUil ODonation
<br />[ilC.......tlon OEnto.nlJlnent
<br />DR.mova' OotMl'(SfMl:tfy)
<br />
<br />I Bg. INSIDE CITY LIMITS
<br />I ~ Yos 0 No
<br />
<br />14b. RELA nONSHIP TO DECEDENT
<br />
<br />Wife
<br />
<br />Not Embalmed
<br />
<br />I 1 ab. LICENSE NO.
<br />
<br />lac. DATE (Mo" DIY. Yr.)
<br />
<br />February 23, 2008
<br />
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITYfTOWN
<br />
<br />STATE
<br />
<br />CBntral Nebraska Cremation ServiCBs
<br />
<br />171. FUNERAL HOME NAME AND MAILING ADDRESS (Street City or Town, Stote,
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />
<br />Gibllon
<br />
<br />Nebraska
<br />l17b. Zip Code
<br />I 68801
<br />
<br />CAUSE OF DEATH (See instructions and examples
<br />
<br />11. PART I. Enter the ellllJIt tJf illllNlbl - en....... InJLlrl.., or complication.. th.. directly C:lul.d the d..th. "bO NOT ente,. tennlnal .vtl'lta .uch ., (:jIrdlae am..,
<br />l1I.plralOl'Y arrest, Or ontn.......,. ftltrUlltion wtthout .hQwlng tn. etiOlogy. DO NOT AaBREVIATE. Ena,. only OM Uti.. IKI _line. Add addltlorW II..., tt Me.Mary.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />I APPROXIMATE INTERVAL
<br />
<br />I onset to death
<br />I
<br />
<br />liml1]ediatp
<br />
<br />I onset to delth
<br />I
<br />
<br />I
<br />
<br />IMMEDIATE CAUSE (Flnol
<br />~s::::.~r condlllon resulllng I) re s n i rat 0 r y
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Ssquenllllly list conditions, II
<br />any, I..ding to the cau..Ustvd
<br />on line a.
<br />
<br />b' 1 uno cancer
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I onset to delth
<br />I
<br />
<br />I
<br />
<br />Enter the UNDERLYING CAUSE e)
<br />(dlselse or Injury thlt Inllllted
<br />the evento ..sultlng In delth) DUE TO, OR AS A CONSI;QUENCE OF:
<br />LAST
<br />
<br />d)
<br />
<br />I on.at to d..th
<br />I
<br />
<br />I
<br />
<br />18. PART II, OTHER SIGNIFICANT CONDITIONS-condltlons Contributing to the deoth but not resulting In the underlying eluse given In PART I,
<br />
<br />18. WAS MEDICAL ExAMINER
<br />OR CORONER CONTACTED?
<br />
<br />Kl YES D NO
<br />
<br />lI:::
<br />UJ
<br />ii:
<br />~
<br />UJ
<br />U
<br />~
<br />!
<br />is.
<br />8
<br />u
<br />OJ
<br />lD
<br />{2
<br />
<br />20. IF FI;MALE:
<br />o Not pregnont within past yelr
<br />o Prqnant .t time of death
<br />o Not pregnont but pregnant within 42 dlYs of dolth
<br />o Not pregnlnt but pregnont 43 dlYs to 1 yelr before deoth
<br />o Unknown If pregnont within the plOt yesr
<br />
<br />211. MANNER OF DEATH
<br />[J Nltu,,1 0 Homlelde
<br />o Aeeldont 0 Pondlng Investigation
<br />o Sulelde 0 Could not be detormlned
<br />
<br />21b.IF TRANSPORTATION INJURY
<br />o Drlver/Operltor
<br />o P....ng.r
<br />o Pedestrian
<br />o Other (Specify)
<br />
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />o YI;S Kl NO
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLHE CAUSE OF DEATH?
<br />DYES IlONO
<br />
<br />220, DATE OF INJURY (Mo., Day, Yr.) /22b. TIME OF INJURY 1220. PLACE OF INJURY-At home, farm, street factory, ornee building. conelruetlon slle, ete. (Specify)
<br />
<br />
<br />22d.INJURY AT WORK? /22e. DESCRIBE HOW INJURY OCCURRED
<br />DYES ONO
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITYfTOWN STATE ZIP CODE
<br />
<br />231. DATE OF DEATH (Mo., Doy, Yr.)
<br />
<br />241. DATE SIGNED (Mo., Day, Yr.)
<br />February 27, 2008
<br />
<br />24b. TIME OF DEATH
<br />
<br />~~
<br />i!,!
<br />_Ill
<br />.!!~>-
<br />~~2!
<br />8.100
<br />"'..,
<br />,gc
<br />o~
<br />"'<1;
<br />
<br />?II ?nns: 1 91100 a m
<br />
<br />124~0rJ!i2 tlee blels or ex,",lpotlon ~rJitor Inves IlIon. In my opinion delth oeeurred
<br />t e ,detelUl<tf>IJlc.t'lIq[due to t CluSe(s) stoted, (Slgneture snd Tille)
<br />
<br />1;1 WI Deputy Hall
<br />
<br />2a. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 12ao. HAS ORGAN OR TISSUE DON.., JPf'N BEEN CONSIDERED?
<br />DYES 0 NO 0 PROBABLY ~ UNKNOWN 0 YES I3iI NO
<br />
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />
<br />m
<br />
<br />z
<br />~:$l:i
<br />'D ~~
<br />:it:~>-
<br />g.tt- ..J
<br />E III <I; Z
<br />8 ffi~ 0
<br />.8 z~
<br />000
<br />...!~
<br />uo
<br />
<br />8:00
<br />
<br />am
<br />
<br />23b. DATE SIGNED (Mo., DIY, Yr.)
<br />
<br />I 23e. TIME OF DEATH
<br />
<br />24e. PRONOUNCED DEAD (Mo., DoY. Yr.) 24<1. TIME PRONOUNCED DEAD
<br />! - .
<br />
<br />23d. To the best of my knowledge, death occurred .t the tlm., date and place
<br />ond due to the couse(s) Stlted. (Slgnlture and Title)
<br />
<br />28b. WAS CONSENT GRANTED?
<br />Not Appllelble II 26a Is NO 0 YES 0 NO
<br />
<br />Lvnelle D Hnmnlka Denlltv Hall Countv Attornev" 211 South L"cu~t Street
<br />
<br />~ l--~""~ru" M.. L / (^""""
<br />~ V' ,(J. -'v'
<br />
<br />Grand Island NE 68801
<br />28b. DATE FILED BY REGISTRAR (MO., DIY, Yr.)
<br />
<br />MAR
<br />
<br />3 2008
<br />
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