|
<br />It
<br />
<br />\
<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, WHICHIS
<br />
<br />::::~~::::;TORY FOR VITAL RECORDS ~~R
<br />tEB 2 9 2008 AS~TA?n:sf4T1 J!iE~JlMR
<br />LINCOLN, NEBRASKA 20080277 1 HEALTli"!"~Ut"~
<br />
<br />
<br />I :~". ,.',..,. '.:' .~:~,~~' ,
<br />
<br />STATEOFNEBRASKA-DEPARTMENTO...FHEALTHAND HUMAN SERVIC,ES. .F 1.~Ml.' ~..,". p....;;....~... ......'........ '''.'1'~. -'2 9 332
<br />--. _"_CERTJFICATEOfDEATH.^.!I,. ..'.....'q .' ,"-
<br />
<br />1, DECEDENT'S-NAME (First, Middle, Last, Suflix) 2, S~X '......,'f t, :.~~ DATE OF DEATH (Mo.. Day, Yr,)
<br />-- Clarence Ludwig Dierking_ ___ Male. August~ 2007._
<br />
<br />4 CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRT~ AGE-La.t Blrthd:L:Y 5b UNDER 1,Y_EAR 5cc UNDER 1 DAY 6, DATE OF BIRTH (Mo., Day, Yr,)
<br />I (Yrs,) MOTjOAYS HOURS MINS.
<br />Lorton. Nebraska ___~ ~ ~ Januar~ 20, 1920
<br />
<br />ja PLACE OF DEATH
<br />-- ~ - 1ll2S:EIIlll ~ Inpallan'- QlJ:JfB: 0 Nursing HomalLTC 0 Hospica Faolllty
<br />8b, FACILlTY,NAME (If not Inst~tu~on, glva sfraat and number) -
<br />o ERIOutpallent 0 Dacodenr. Home
<br />St. Francis Medical Center
<br />o ll)\ DOther(SpeoifyL_.
<br />-~------------._-~~ -"- .
<br />80, CITY OR TOWN OF DEATH (Includa Zip Coda) , ad COUNTY OF DEATH
<br />Grand Island 68803 ~ Hall
<br />
<br />9a, RESIDENCE:'STATE "'=r. COUNTY Eo, CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />-~-'_.._~ --
<br />9d, STREET AND NUMBER 9.. APT, NO
<br />
<br />
<br />9g.INSIDE CITY LIMITS
<br />
<br />Xl YES 0 NO
<br />
<br />1417 N. Huston 68801
<br />10.. MARITAL STATus ATTlME OF DEATH Ol Marriad 0 Never Marr~:NAME OF SPOUSE (First, Middle, La.t,SUflix) If wife, give m~lden nam~,
<br />
<br />DMarried,butsaparated OWldowed ODlvorcad DUnknown _L Irene Niebrugge
<br />
<br />11, FATHER'S-NAME ~i;~id Mlddla, D~:~ki~g Suflfx) '-112 MOTHE~'S'NAME (~iia - M:ddj';:--"--- D:::~ surna~'-)
<br />
<br />1~'(M!N Ut!~~7 t~4Ep T'tj~af't'.!..'1'~04~ye., 14a.INFORMANT.NAME. . 14b, RELATIONSHIP TO DECEDENT
<br />(Ye., no, or unk,) Irene D1.erk1.ng Wif e
<br />
<br />15'~::r~~OFDI~~:~::i:~ _~at~!~;]~:,::N~;iE Eth , r16/,5Ero, 1~:~~~~0"~7'.Yr, ~oo;-
<br />
<br />o Cremallon 0 Entombmant 18d, CEMEaEMATORY OR OTHE~CATION CITY /TOWN STATE
<br />
<br />o Removel 0 Othar (Spacify)
<br />
<br />Westlawn Memorial Park Cem~ry
<br />
<br />Grand Island. Nebraska
<br />
<br />17., FUNERAL HOME NAME AND MAILING ADDRESS (Straal, Clly or Town, State)
<br />Apfel Funeral Home, 1123 West Second.
<br />
<br />PART I. Enter the chain of .V""l,udise.se., injuries, or complloelions--thal direotly oaused the death. DO NOT entar lermlnal avents such as cardiac arrest,
<br />re.plratory arrast, Or ventrloular fibrillation without showing the etiology, DO NOT ABBREVIATE. Enter only one ceuse on a line, Add additlonallinas if nacessary,
<br />IMMEDIATE CAUSE:
<br />
<br />onset to deeth
<br />
<br />IMMeDIATE CAUSe (Flnel
<br />disease or condlUon ,""lUng
<br />In_)
<br />
<br />(a) I' A/ 1M M-d/V r4
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />,)wJ(
<br />
<br />onset to death
<br />
<br />SequentlaUy Ult condlllonl,lI (h)
<br />any, ,"ding 10 thlo,u" U.lod DUE TO, OR AS A CONS.EQUENCE'-OF-;----
<br />on linea.
<br />Entarthe UNDERLYING CAUSE
<br />(dl...... Dr InJurylhetlnltlatad (c)
<br />Ih....nls resulting In death) DUE TO, OR AS-A CONSEQUENCE (jf,-----'
<br />LAST
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />18, PART U, OTHER SIGNIFICANT CONDITIONS-Condlllon. contributing to the death but not re.ultlng in the underlying oau.a given In PART I.
<br />
<br />---.!21/11 wrtL
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />o YES j(N0
<br />
<br />20, IF FEMALE: 21a, MANNER OF DEATH 21 b, IF TRANSPORTATION INJURY 210. WAS AN AUTOPSY PERFORMED?
<br />o Not pregnent within past year 'jCj,Nalural 0 Homiolde 0 DrivarlOparator
<br />
<br />o Pregnantelllme of death 0 AccidantO Pandlng Inv..tlgatlon r.J Passenger
<br />
<br />o Not pragnant, but pregnant wilhin 42 d.y. of death 0 Suloide 0 COuld not ba determined Q Pede.lrian 21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o Not pregnant, but pregnant 43 days to 1 year befora death 0 Olhar (Specify) COMPLETE CAUSE OF DEATH?
<br />o Unknown If pregnant within the pasl year 0 YES 0 NO
<br />
<br />22a DATE OF INJURY (M~ ' O~ LTIME OF INJUR: [22e, PLAC~ OF INJURY-At home, farm, .treet, factory, office bUilding construollon Site, etc (Speolfy) ==._
<br />
<br />22d, INJURY AT WORK? 1::2e, DESCRIBE HOW INJURY OCCURRED
<br />DYES 0 NO
<br />--- -~ ~~-~------""'~.----------..... -~ - ----
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO, CfTYfTOWN STATE ZIP CODE
<br />
<br />DYES
<br />
<br />~NO
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />."_~,_.-I ~-=-_O
<br />
<br />24a, DATE SIGNED IMo" Dey, Yr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />m
<br />
<br />;z:>-
<br />~:!!l;!
<br />III a:
<br />~>-O
<br />~if~~
<br />!; ." i: ;z:
<br />llffi;z:O
<br />lliii=>
<br />,2li:8
<br />815
<br />
<br />m
<br />
<br />23c, TIME OF DEATH
<br />0(,
<br />
<br />240, PRONOUNCED DEAD (Mo., Day, Yr,) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />2413. On the basis of examination and/or Investigation, in my opinion dealh occurred at
<br />the time, data and place and dua to the eause(.) stated. (Signatura and Tllla) T
<br />
<br />25, DID TOBACCO USE CONTRIBUTE TOTHE DEATH?
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicabl~ if 26a Is NO 0 YEs..-'tI NO
<br />
<br />-----.9_~~,JO _0 PROBABL~_UNKNOW,,~9.~__~______.
<br />27. NAME, TITLE-i\IiDADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />David Colan M.D. 729 N. Custer Ave., Grand Island, NE
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />68803
<br />
<br />28b, DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />AUG 3 0 2007
<br />
|