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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AN(J HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL.RECflBD.ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAI/$frC$.~cffiliNFWH'Cf1JS
<br />
<br />:::::::::~:;RY FOR WTAL RECOROS'~!~ER
<br />r" E 8 n 7 Z006 2 0 0 8 0 3 1"") 8 ~ASSIStAiv'r stATE;R~tSthAR
<br />LINCOLN, NEBRASKA , '*Jl.L1H AND HUM14N..sERVicES
<br />~ -. " .:,,-' ~ =--
<br />
<br />'-
<br />
<br />- - ~- '-.':;:::'jl::: . - ~
<br />I .-- "":' - - "'..- , , ,'" .....-
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH ANO HUMAN SERv!~~Stll':lA~I?~~~:~FPORTO' - 5'
<br />__. _ C..J;,BJIFJCATE OF DEATH.,-.--., _.__.._. _
<br />3. DATE OF DEATH (Mo" Day, Yr.)
<br />December 16, 2005
<br />
<br />142~~
<br />
<br />
<br />Suffix)
<br />
<br />2. SEX
<br />Female
<br />
<br />DECEDENT'S.NAME
<br />Imogene
<br />
<br />(First,
<br />Louise
<br />
<br />Middle,
<br />Lechner
<br />
<br />Las\,
<br />
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />
<br />Sc. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />S.. AGE.Last Birthday 5b. UNDER 1 YEAR
<br />
<br />(Yrs.) 79 MOS. DAYS
<br />
<br />January 2, 1926
<br />
<br />Loup County, Nebraska
<br />
<br />Sa. PLACE OF DEATH
<br />HO.SEJIAl.: D Inpali.nt
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />508-12-0169
<br />
<br />QlliE!J: D Nursing Home/LTC 0 Hospice Facility
<br />
<br />8b. FACILITY. NAME (It not institution, give slre.1 .nd number)
<br />
<br />D ER/Outpatl.nt
<br />
<br />)lI D.c.dent', Hom.
<br />
<br />4311 W 13th St.
<br />
<br />D CO\ D Oth.r (Spaclly)
<br />
<br />. lad. COUNTY OF DEATH
<br />Hall
<br />
<br />lac CITY OR TOWN - -_.
<br />Grand Island
<br />
<br />8e. CITY OR TOWN OF DEATH (Includa Zip Cod.)
<br />Grand Island 68803
<br />
<br />.~-
<br />
<br />9a. RESIDENCE.STATE
<br />Nebraska
<br />
<br />9b. COUNTY
<br />Hall
<br />
<br />
<br />9t. ZIP CODE
<br />68803
<br />
<br />9g. INSIDE CITY LIMITS
<br />D YES ~NO
<br />
<br />9d. STREET AND NUMBER
<br />4311 W 13th St.
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH IllMarrled U Nevor Marriad lOb. NAME OF SPOUSE (First, Middle, Last, Sullix) II wile, glvo maiden nama.
<br />
<br />o Married, but .eparalod D Widowed D DI.vorc.d 0 Unknown Teddy Lechner
<br />
<br />Suffix) '112. ~c;;~~.N(~:tF;I:~U9h Middle,
<br />
<br />Molden Surname)
<br />
<br />FATHER'S.NAME (First, Middle,
<br />Fredrick C. Neumann
<br />
<br />Last,
<br />
<br />(Yes, no, or unk.)
<br />
<br />
<br />16b, UCEi.'~~O.
<br />/tR:I
<br />
<br />16c. DATE (Mo., Dey, Yr.)
<br />December 20, 2005
<br />
<br />STATE
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dale' olservle.11 yes.
<br />NO
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />1!!1 Burial
<br />
<br />D Donation
<br />
<br />D Cremollon 0 Enlombment
<br />
<br />15d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY /TOWN
<br />
<br />D Removel U Olher (Spocily)
<br />
<br />west1awn Memorial Park Cemetery, Grand Island, Nebraska
<br />
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City orTown, Stale)
<br />Kleine Funeral Home, 3213 W North Front St., Grand Island, NE
<br />
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />PART l. Enter the chain of evenls--diseases, injuries, or complications..lhal directly caused the dealh. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arresl, or ventrlculBr fibrillation without showing Ihe etiology, DO NOT ABBREVIATE. Enter only One cause on a line. Add additional lines if necessary.
<br />
<br />I
<br />I
<br />
<br />I Onset to death
<br />i
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />.l
<br />I
<br />I
<br />I
<br />
<br />
<br />~! .,
<br />. /,
<br />. i';It.,.~'!.:? 'no::C!..-LLi;'",fU<""l
<br />
<br />~?- - 3 I. Il-}
<br />
<br />(a)
<br />
<br />IMMEDIATE CAUSE (Ftnol
<br />dIsease or condition resulting
<br />In death)
<br />
<br />Sequentially II.t oondlllons, If (b)
<br />any, leading to the ceu.ellsted -DUE TO,ORASA'CONSEQUENCE OF:
<br />on IIn8 a.
<br />Enter the UNDERLYING CAUSE
<br />(disees.o, InJUry that Inltleted (c)
<br />theevenlore.ultln9Indoalh) DUE TO, OR AS A CONSEQUENCE OF:
<br />lASI"
<br />
<br />onset to death
<br />
<br />onset to death
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />tB. PART II. OTHER SIGNIFICANT CONDITIONS.Condlllons conlributlng 10 the doath but not rasultlng In Ihe underlying ceuse given In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />DYES iI NO
<br />
<br />21~. MANjI~R OF DEATH
<br />.'\l:.t4Jatural 0 Homicide
<br />
<br />201 FEMALE:
<br />...JZf Not pregnant within past year
<br />o pr.gnant el time 01 d.alh
<br />o Nol pregnant, but pregnant within 42 days of death
<br />D Nol pregnanl. bul pr.gnanl43 doys to 1 yeer belore death
<br />D Unknown II pregnant within th. p.st y..r
<br />
<br />Q AccidenlD Pondlng Investigstion
<br />
<br />21 b.IFTRANSPORTATION INJURY
<br />D Drlver/Op.rator
<br />
<br />D P....nger
<br />
<br />D P.deolrlan
<br />
<br />D Olher (Specily)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />COMPLETE CAUSE OF PEAHI?
<br />o YES ~/~O
<br />
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />/'
<br />D YES UNO
<br />
<br />D Suicide D Could not be determined
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY.At home, larm, otrool, factory, offico building, construction ,ite, elc. (Speclly)
<br />m
<br />
<br />22a. OATE OF INJURY IMo., D.y, Yr.)
<br />
<br />22d.INJURY AT WORK?
<br />
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />
<br />DYES D NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />CITY/TOWN
<br />
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<br />0"'0
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<br />~~
<br />0(
<br />
<br />.3a. DATE OF DEATH (Mo" Doy, Yr.)
<br />
<br />December----l6- 20010'_
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />
<br />24c. PRONOUNCED DEAD (Mo" Dey, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />240. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
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<br />
<br />24e, On the basis of examination and/or investigation, in my opinion death occurred at
<br />the lima, d.le .nd placa and due to Ihe c.useI5) st.led. (Signature .nd Tille) l'
<br />
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />~O
<br />
<br />26b. WAS CONSENT GRANTED?
<br />~ /"
<br />Not Applicable II 28a is NO DYES 'tl NO
<br />
<br />Island,NE 68803
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