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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL THAND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL~E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAn -- ,~'-~ -- -:~HIS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ! =~~~;~~ " "'r€,,'=~. \
<br />
<br />DATE OF ISSUANCE
<br />
<br />NOV 1 6 2006 2 0 0 8 0 3 6 3 7
<br />
<br />LINCOLN, NEBRASKA HEJiC:TH ANa" "
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVlltES F "
<br />CERTIFICATE OF DEATH ~l;,_~~o;".;~,- b
<br />
<br />Middle,
<br />
<br />Sulllx)
<br />
<br />
<br />
<br />/~",-~"'t.
<br />
<br />L..I,
<br />
<br />Elba. Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />5a. AGE.Lasl Birthday 5b, UNDER 1 YEAR
<br />(Yrs,) MOS. DAYS
<br />
<br />76
<br />as, PLACE OF DEATH
<br />
<br />6c, UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />6. DATE OF BIRTH (1.10.. Day, Yr,)
<br />
<br />May 1, 1930
<br />
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<br />
<br />506-32-8567
<br />ab. FACILlTY.NAME (11 not Institution, glvo stroot end number)
<br />
<br />~:
<br />
<br />iii Inpatlenl
<br />
<br />QllJEB 0 NUl1llng Hom.IlTC [J Hospice FaClll1Y
<br />
<br />o ER/oulpatienl
<br />
<br />o Decodent's Horne
<br />
<br />,,"". ...."~, ".....'-~..,<-
<br />
<br />[J ~~
<br />
<br />",0 Olher(SpeClfyl., '
<br />."-~..""-:~',~ -.',7-,&'.
<br />ad. COUNTY OF DEATH
<br />
<br />,SQiijU" l'aaqis Mealca1-~nter
<br />8c. CITY OR TOWN OF DEATH (Include ZIp Code)
<br />
<br />Grand Island 68803
<br />\la, RESIOENCE-STATE
<br />
<br />!Xl, COUNTY
<br />
<br />
<br />68835
<br />
<br />Nebraska
<br />lid, STREET AND NUMBER
<br />
<br />Howard
<br />
<br />aUIP CODE
<br />
<br />9g, INSIDE CITY LIMITS
<br />IJiI YES [J NO
<br />
<br />318 12th St.
<br />
<br />loa, MARITAL STATUS ATTIME OF DEATH iii Married [J Never Mam.d lOb, NAME OF SPOUSE (First, Mlddl., Last, Sufllx) II Wile, give maiden name,
<br />
<br />[J Mam.d, bula.paral.d 0 Widowed 0 DIvorced 0 Unknown
<br />
<br />Zeta Radke
<br />sulllx)
<br />
<br />12. MOTHER'S-NAME (First,
<br />Helen Hansen
<br />
<br />Mlddl.,
<br />
<br />Malden Surname)
<br />
<br />11. FATHER'S.NAME (Firat,
<br />Clarence La her
<br />13, EVER IN U,S, ARMEO FORCES? Give dales 01 service Uy.., 14a,INFORMANT-NAME
<br />(Yes, no, orunk,) Yes
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />
<br />
<br />Wife
<br />
<br />16c,OATE (1.10" Day, Yr,)
<br />
<br />November 6, 2006
<br />
<br />STATE
<br />
<br />15, METHOO OF OISPOSITION
<br />IJI Burial 0 Donation
<br />
<br />o Croma~on 0 Enlombmenl
<br />
<br />'CITY /TOWN
<br />
<br />[J Removal OOlheqSpeclfy)
<br />
<br />SI. Joseph's Catholic Cemetery
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESSdStre.1. CIIY or Town, Stat.)
<br />Jacobsen-Greenway Funeral Home, 411 Street, PO Box 112, SI. Paul, Nebraska
<br />
<br />Nebraska
<br />17b. Zip Cod.
<br />68873
<br />
<br />Elba
<br />
<br />
<br />examplee>
<br />18. PART-i. Enturtne-chaln o/llvenls--d1C...u, InJUll.., or eomplleeUons..lhal d1r&C"~ caus.d Iho d.ath, 00 NOT .nlort.nnlnol evenm sud10s cardlae arrest,
<br />re.plralory arresl, or venlrlcular IlbrJllallon wllhout showing the .tiology. 00 NOT ABBREVIATE, Enter onlY on. caua. on a line, Add addl~onalllnesU necessary.
<br />IMMEOIATE CAUSE:
<br />
<br />(a)
<br />
<br />
<br />~PPROXIMATF INTERVAL
<br />
<br />onset to d.alh
<br />
<br />IMMEDIATECAUSE(Fnal
<br />dll.... cweondnlonraounlng
<br />n d..th)
<br />
<br />
<br />onset to death
<br />
<br />Sequ.ntl.11Y II.t eondllloh', n
<br />sny ,leading to tho cau.. n.led
<br />on In..,
<br />Ent...,. UNDERLYING CAUSE
<br />(d...... or inJury th.t initiated
<br />\he .von.. ra.ullng h dOl")
<br />LJ6J"
<br />
<br />(h) -,.{.(f#~
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />b
<br />
<br />t1'k
<br />
<br />onset 10 d.ath
<br />
<br />(e)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />ons.t 10 d.ath
<br />
<br />(d)
<br />
<br />16, PART II, OTHER SIGNIFICANT CONDITIONS-Condlllon. eonlrJbullng 10 Ih. death bul notr.811lting In the und.rlylng caus. glv.n In PART I,
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />[J YES a NO
<br />
<br />~p~
<br />
<br />
<br />ffi
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<br />
<br />I
<br />c!l
<br />{1.
<br />
<br />21b,lFTRANSPORTATION INJURY
<br />a DrIv.r/Op.rator
<br />
<br />o Passenger
<br />
<br />o Ped.slrJan
<br />
<br />o Olller (SpeCify)
<br />
<br />21C, WAS AN AUTOPSY PERFORMED?
<br />
<br />20, IF FEMALE:
<br />
<br />
<br />[J Nol pregn.nl within put ~..r
<br />
<br />o Pregnant alllme of dealh
<br />
<br />o Not pregnant, but pragnanl wllhln 42 da~o 01 dealll
<br />
<br />o Nol pregnant, bulprognent 43 days to 1 yaarbe/ore death
<br />
<br />a Unknown U pr.gnant wllhln Ihe past year
<br />
<br />21a, MANNER OF DEATH
<br />\fiatural a Homicide
<br />
<br />a Accldenla P.ndlng Inv.sagation
<br />
<br />o Suclde 0 Could not be detennlnod
<br />
<br />DYES
<br />
<br />~O
<br />
<br />21d, WERE AUTOPSY ANDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />22d, INJURY AT WORK?
<br />
<br />
<br />- 22a, OATE OF INJURY (Mo.. Day, Yr,)
<br />
<br />221l. TIME OF INJURY 22CT.1'LACE'"OF INJURY-A! home, tarm, 81r8*l; i.-ctory; omeebulldlng, conS!lUCtto"sllerule. (Sp9etfy)-
<br />m
<br />
<br />DYES 0 NO
<br />
<br />221, LOCATION OF INJURY - STREET & NUMBER, APT. NO,
<br />
<br />SlATE
<br />
<br />ZIP CODE
<br />
<br />CfTYlTONN
<br />
<br />!'~
<br />i~
<br />"Ill!!
<br />Q.:I:~
<br />E"'Z
<br />8 ~o
<br />1l~
<br />.2~
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<br />
<br />23a, OATE OF OEATH (Mo" Day, Yr,)
<br />t,.. -0 to
<br />
<br />24a, OATE SIGNED (Mo.. Day, Yr,)
<br />
<br />24D, TIME OF DEATH
<br />
<br />:i1ii
<br />!'UZ
<br />i~~
<br />......io(~
<br />E."'/:i5
<br />~~!i
<br />~li!8
<br />811
<br />
<br />26a, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />m
<br />
<br />
<br />23e, TIME OF OEATH
<br />,qO){
<br />
<br />m
<br />
<br />24c, PRONOUNCED DEAD (Mo.. Day, Yr.) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e, On the ba"s 01 8X.rrina~on end/or Invesllgallon,In my opinion dealh occurred at
<br />the time, dale end place and du.lo the cause(s) stal.d, (Signature and Tille)"
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />Nol Appllc.bleII 26a 10 NO [J YES ,NO
<br />
<br />ff~
<br />
<br />?VI {rK/(
<br />
<br />29b, OATE FILEO BY REGISTRAR (Mo" D.y, Yr,)
<br />NOV 1 4 2006
<br />
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