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<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ~~fiRVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGIN~t;ct~R 9tl:F1LIiE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL 5T~~~.ECT"ill/W1!l/fti {5
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. > ~"i>' ~ "'<';1\ ~- ":-::-'<;..;,
<br />. ;. <I ji
<br />DATE OF ISSUANCE ,-', ; : . ~.~) '~
<br />APR I 9 2008 I"; : 'AN!-El( Sl!rCOOP.~ .'
<br />LINCOLN, NEBRASKA 20 0 80 5 8 6 6 'A~/$TAMtsrAre:BfGlST81fl1 :",
<br />H~Alff'1. AND HUMAN 5ER~fC.~ .,,/
<br />, .....~" . \ . c,..,.,
<br />, .....', /''''('' ).
<br />STATE OF NEBRASKA. DEPARTM_E~! O!!I~L TH AND HUMAt4~~~!Oi i? ~'~JM~'~\:--~:'" ~i19
<br />UI- ........ > ,~ \.1.0; {"A''If.t!:'~
<br />1.DECEDENTS.NAME (Firat, Middle. Le.t, Sufllx) 2. SEX ". ...'DAT"'?F.P~"H (Mo..Dey,Vr.l
<br />"'. ." ".c.'.>
<br />.A,prTI19,2008
<br />
<br />Lillian Christine Rieger
<br />
<br />4. CITY AND STATE OR TERRlTORV, OR FOREIGN COUNTRV OF BIRTH
<br />
<br />Female
<br />
<br />S; DATI! OF BIRTH (Mo., Dey, Vr.)
<br />
<br />ic. UNDER 1 DAV
<br />HOURS, MINS.
<br />
<br />i.. AGE-L"I Blnhd.y
<br />(Vra.)
<br />
<br />lb. UNDER 1 YEAR
<br />MOS. I DAYS
<br />
<br />April 6, 1916
<br />
<br />Bentley, North Dakota
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />92
<br />
<br />Se. PLACE OF DEATH
<br />HaaElIALllXllnpau.nl
<br />o ERIOutpaUenl
<br />o DOA
<br />
<br />lllIIEB: 0 Nuralna Home/LTC
<br />o Qecedent'e Home
<br />OOlh.r(Speclfy)
<br />
<br />o Hoeplc. Feclllty
<br />
<br />550-18-9948
<br />
<br />Sb. FACIUTY-NAME (If not IneUtuUon, atve etraet .nd number)
<br />
<br />'!
<br />
<br />Saint Francis Medical Center
<br />
<br />Sc. CrN OR TOWN OF DEATH (lnclud. Zip Code)
<br />Grand Island 68803
<br />
<br />lId. COUNTY OF DEATH
<br />Hall
<br />
<br />I.. RESlDENCE-8TATE lIb. COUNTY I BE. CITY OR TOWN
<br />Nebraska Hall I Grand Island
<br />Id. STREET AND NUMBER 110. APT. NO. T II. ZIP C, ODE
<br />4335 Calvin Drive 68801
<br />10.. MARITAL STATUS AT nME OF DEATH IiIM.mod 0 N....er M.medI1Ob. NAME OF SPOUSE (Firat, Middle. L..t, Sufllx) Ifwlfo. al.. melden n.me.
<br />o Mamed, bUI ..paraled 0 Wldow.d 0 DI.orcod 0 Unknown I Benjamin E Rieger
<br />11. FATHER'S-NAME (Flral, Mlddl.. Lae~ Suffix) 112. MOTHER'S-NAME (Flral, Mlddl.. Malden Surname)
<br />John Huber Eva Eberhart
<br />13. EVER IN U.S. ARMED FORCES? GI.o d.lal of .....le.1f VOeT14a.INFORMANT-NAME
<br />(V,., No, or Un~.) No Beniamin E Rieaer
<br />1&. METHOD OF DISPOSITION is.. EMlIALMER-SIGNATURE
<br />C Surlol oDonalloo
<br />!iilc.......'o. oEmom-
<br />ORomOVIl Ooth.rtOpocllyl
<br />
<br />:)
<br />II-
<br />~
<br />al
<br />l!:::
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<br />
<br />is.
<br />E
<br />o
<br />o
<br />.z
<br />o
<br />l-
<br />
<br />llg. INSIDE CITY LIMITS
<br />IiSl V.. 0 No
<br />
<br />14b. RELAnONSHIP TO DECEDENT
<br />
<br />Husband
<br />
<br />Not Embalmed
<br />
<br />I 16b. LICENSE NO.
<br />
<br />April 21, 2008
<br />
<br />1lc. DATE (Mo., D.y, Vr.)
<br />
<br />1ld. CEMETERV. CREMATORY OR OTHER LOCATION
<br />
<br />CITYfTOWN
<br />
<br />STATE
<br />
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />
<br />Central Nebraska Cremation Services
<br />
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Streat, City or Town. Stal.)
<br />All Faiths Fuo.eral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />
<br />Gibbon
<br />
<br />CAUSE OF DEATH (See instructions and examples)
<br />1L PAMT I. Enter.__ ~ oI.wna _ dl......,lnjurte.. or compllCltlon.. tMt dlreetl~ CIUHd.t. Math. DO Mol .m-r "fiftlnal eventt ,uch .. canUK .,...t,
<br />I'iIlpiratory.......... tit ,.,.ntf1cu.... ftbrtllatlo.- WIthout showing the Itlology. DO NOT ABBREVIATE. EnM:t only one C8UIIII on _ lint. Add addltlon.III"''' tt "ece...ry.
<br />IMMEDIATE CAUSE:
<br />
<br />'~'\Jl , I f'Ir..,~;-;",
<br />DUI! TO. ~R AS A CONSEQUENCE OF:
<br />
<br />I APPROXIMATE INTERVAL
<br />I
<br />
<br />: on~o~:~ _
<br />
<br />
<br />on..t to d.ath 0
<br />I
<br />
<br />I
<br />
<br />IMMEDIATE CAUSE (Final
<br />dlaaale or condition relultlna
<br />In de.th)
<br />
<br />S.quenti.lly lIat coodlllone, II b)
<br />any. I..dlng to the caus.li.ted
<br />on line a.
<br />
<br />on..t to d..th
<br />I
<br />
<br />I
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />Enter tho UNDERL YlNG CAUSE c)
<br />(dl..... or Injury th.t Inltlalod
<br />the .....nle mulllnaln d..lh) DUE TO. OR AS A CONSEQUENCE OF:
<br />LAST
<br />
<br />onaet to d.ath
<br />I
<br />I
<br />I
<br />11. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />o VES ILJ-1'b
<br />
<br />d)
<br />
<br />~' 0:-::-~~':'__~;'h~~\I\::~::~-_.'-'
<br />
<br />!!:! 20. IF FEMALE: 0 21a. M""'NER OF DEATH 21b.IF TRANSPORTATION INJURV
<br />~ gNot pragn.nl within pa.t year @.I6tur.1 0 Homicide 0 Drlver/Oper.tor
<br />ffi 0 praanant at Urn. of doath 0 Accident 0 Pandlng In.lltlgatlon 0 paoaanaer
<br />~ 0 Not pregnant, bul preanant within 42 d.yo of d..th 0 Sulcldl 0 Could not be d_ned 0 p.doatrlan
<br />1; 0 Not pregnant, but pragn.nl 43 d.ye to 1 year befora d..th 0 Othar (Specify)
<br />j OUn~nown II preanant within the p..t year
<br />
<br />a.
<br />e
<br />o
<br />- .!-.
<br />{!.
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />o VES lll1lo
<br />
<br />21d. WERE AUTOPSV FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />
<br />o Y1!S II]..t(O
<br />
<br />22a. DATE OF INJURY (Mo.. DIY. Vr.) \22b. nME OF INJURV 122c. PLACE OF INJURV-AI home. fann. Itreat, factory. offlca bulldlng, conetructloo .11.. .tc.(Speclfy)
<br />
<br />
<br />22d~~~:VA~RK? 122..DESCRIBIiHOWINJURYOCCURRED-' .... -- ---- ~--~-- -- -'- ----------
<br />
<br />
<br />221. LOCAnON OF INJURV _ STREET. NUMBER, APT. NO. CITYfTOWN STATE ZIP CODE
<br />
<br />23.. DATE OF DEATH (Mo.. Day, Vr,)
<br />
<br />248. DATE SIGNED (Mo., Day, Vr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />\
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<br />
<br />'---'
<br />
<br />z
<br />
<br />~~ April 19. 2008 ~~~
<br />
<br />i ~)o 23b. DATE SIGNED (Mo.. Day. Vr.) \ 23c. TIME OF DEATH J ~ ~)o 24c. PRONOUNCED DEAD (Mo., D.y, Vr.) 24d. TIME PRONOUNCED DEAD
<br />
<br />~~;i Aoril?1 ?nnQ ,,,,.en om C1.lI.o(~ m
<br />0.::0 8E~~0
<br />~:;;; J~' To the ~ mr:k odga, death occurred .1 tho Urn., d.1e .nd pl.c, W Z 248. On tho baal. of examln.tlon and/or Inveatlgallon, In my opinion dealh occun-ed
<br />~ ~ ~ \ and d~o c (a) 1~.tSI"nalura .nd nil') 11 is 5 .t tha Ume. d.1e .nd place Ind due to Iha cauoo(ol.taled. (Slanatura .nd Tlllo)
<br />
<br />~o( q.l1.... _ c\ ~ \:h ~ 8~
<br />
<br />2&. DID TOBACC~ ~\E CONTRI~E TO THE DEATH? T281. HAS ORGAN OR nSSUE OO~ BEEN CONSIDERED?
<br />o VES m1GO' 0 PROBABL V 0 UNKNOWN 0 VES KJ..-tfo
<br />
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHVSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEVI(Type or Prlnll
<br />
<br />m
<br />
<br />12Sb. WAS CONSENT GRANTED?
<br />Not Appllc.ble If 2S. I. NO 0 YES Il:)jIe
<br />
<br />RVl'In Cronrh
<br />26.. REGISTRAR'S SIGNATURE
<br />
<br />D n . 800 Aloha st.
<br />
<br />I;~' ~-n~ A.
<br />
<br />V-
<br />
<br />Grand
<br />f--..
<br />
<br />- '8..
<br />
<br />Nebraska 68803
<br />26b. DATE FILED BV REGISTRAR (Mo., Day. Vr.)
<br />
<br />Island
<br />
<br />p
<br />
<br />APR 2 4 2008
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