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<br />STATE OF NEBRASKA
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<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 SECTIr;J.N1 WHICH IS
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<br />:::;::~~~~::;TORY FOR VITAL RECORDS. ~"',,, . . ::~:. i;';:~~f:"
<br />5 9 6 0 . ~0":iiIITANLlf.S. aopPliR
<br />MAR 2 1 2008 2 0 0 8 0 AS$ISTANT..$:rA:rJ;, REG1$T;8,Afl
<br />LINCOLN, NEBRASKA 16!If,L TH~4WlY'A{)I SEf/...vLc,ES
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<br /> STATE OF NEBRASKA. DEPARTMENT ~~~.!:. T_H_~NO ~~M!,N RICE '08 :'~:t8 29
<br /> L;,,"I'C II..IL:ATE DEA I H '-,'" .~. --
<br />\'~ 1.DI!CEDENT'S.NAME (Firat, Middle, Last, Sumx) ,.,2.i~j', f;~fE .~'~eAfH (Mo"Day,Yr.)
<br /> .~ . '.:.";'/;; fH'.~ .' ,\ "
<br /> Geraldene Leona Springsguth - RAtrlale' . .. . . . . Marchio, 2008
<br />\;!\ 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Go. AGE-L..t Blrlhd.y Gb. UNDER 1 YEAR ,G;o"".Nrii!ilIilP\v 'i ',: ~d)ATEOF BIRTH (Mo.. D.y, Yr.)
<br /> (Yra.) MOS. I DAVS HOURS.'I' MINS.
<br /> Phillips, Nebraska 90 March 22,1917
<br /> 7. SOCIAL SI!CURITY NUMBER 80, PLACE OF DEATH
<br />b 508-01-2012 I:IQlleJI&.i 0 Inp.lI.nt 2Il::t.liB: IXI Nur.lng Home/LTC o Ho.ploo Faolllty
<br />~.j 8b. FACiLITY.NAME (II not Inotltution, give atr..t .nd numb.r) o ERlOutp.ti.nt o D.c.d.nt'. Home
<br />Grand Island Veterans Home oDOA o Other(Spoclly)
<br />..J 8.. CITY OR TOWN OF OEATH (Includ. Zip ,Coda) ISd. COUNTY OF DEATH
<br />~ Grand Island 68803 Hall
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<br />z 00. RESIOENCE.ST ATE lOb. COUNTY Oc. CITY OR TOWN
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<br />11. Hall Grand Island
<br />~ Nebraska
<br />"tl od, STREET AND NUMBER 10" APT. NO. 101. ZIP CODE log. INSIDE CITY UMITS
<br />.! 210 Brookline Drive 68801 I&J Va. 0 No
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<br />~ lUa. MARITAL STATUS AT TIME OF DEATH 0 Marrlad o N.var MarrlsdllUb. NAME OF SPOUSE (Firat, Middle, L..t Sumx) II wllo, glv. m.ld.n nsme.
<br />~ o Marrledl but separated 00 Widowed o Dlvorc.d o Unknown Wilbur SllrinQsguth
<br />C. Mlddlo, Suffix) 12. MOTHER'S-NAME (Firat, Mlddl., Malden Surnamo)
<br />~ 11. FATHER'S.NAME (Flr.t, L.at,
<br />C) Fred Weiler Anna Barr
<br /><l> 14b. RELATIONSHIP TO OECEDENT
<br />CD U, EVER IN U.S. ARMED FORCES? Glv. date. of oorvlc.1I ya"1 14a. INFORMANT-NAME
<br />0 (Va., No, or Unk.) No Howard SorinQsQuth Son
<br />...
<br /> lG. METHOD OF DISPOSITION 160. EMBALMI!R-SIGJoIATURE I 1Gb. LICENSE NO. lGc. DATE (Mo., D.y, Vr.)
<br /> o Burial OOomlllon Not Embalmed March 17, 2008
<br /> IiI Cnunatl(tn o Eniombment 16d. CEMETERV, CREMATORV OR OTHER LOCATION CITYfTOWN STATE
<br /> oR.monl o Oth.r(Sptu;:ItYJ
<br /> Central Nebraska Cremation Service Gibbon Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (stro.t City or Town, State) 1?b. Zip Coda
<br /> All Faiths Funeral Home, 2929 S, Locust Street, Grand Island, Nebraska 68801
<br /> CAUSE OF DEATH (See Instructions and examples)
<br /> 1'. PART I. Enter th. . dl.....s, Injurie!J;, or complication.. th<<.. dl"'clI~ ~u..~ the d..th. DO NOT 8nlor ..nnln.a avent, ,UiOn It cardl.c .mtst, I APPROXIMATE INTERVAL
<br /> .....pir.tory ane..t, Ot ....rUrh;;ular Ilbrlil.t1(1r1 wl'hout showing tlte eilology. DO NOT ABBREVIATe. EnUlr O"I~ Ollll ..au.. on I 11n.. Add ..ddIUonlllln.. If n......ary. I
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMI!DIATE CAUSE (Fln.1 I
<br /> dls.ase Dr condition r..i.dtlng .) Cardiovascular Accident '< 1 VPClr
<br /> in d.ath)
<br /> DUE TO, OR AS A CONSEQUENCE OF: I on..t to d.ath
<br /> I
<br /> S.quenUall)' IIsl COlldltions, It b) ,
<br /> any, leading to the cause listed
<br /> on line .. DUE TO, OR AS A CONSEQUI!NCI! OF: onset to death
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<br /> Entar th. UNDERL VING CAUSE c) I
<br /> (dl..... or Injury th.t Inltl.ted DUE TO, OR AS A CONSEQUENCE OF:
<br /> the 8venll reSulting In dllll.Ul) onaet to death
<br /> LAST I
<br /> I
<br /> d)
<br /> 18. PART II, OTHER SIGNIFICANT CONDITIONS-Condition. contributing to tha d..th but not r..ulllng In th. undorlylng causa glvon In PART I. 10. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> Diabetes Mellitus Type 2, Atrial Fibrillation DYES ii NO
<br />It:
<br />w 20, IF FEMALE: 211. MANNER OF DEATH 21b.IF TRANSPORTATION INJURV 21c. WAS AN AUTOPSV PERFORMED7
<br />u:
<br />i= IX! Not pr.gnont within p..t y.ar ~atural o Homlcld. o Drlv.r/Oper.tor DYES ~NO
<br />It:
<br />W o pregn.nt .t 11m. 01 do.th o Accld.nt 0 P.ndlng Inv..lIg.lIon o P....ng.r 21d. WERE AUTOPSV FINDINGS AVAILABLE
<br />C) o Not pregnant, but pregnant within 42 duya of death o Sulcld. o Could not b. d.t.nnlnod o Pod.atrl.n
<br />~ TO COMPLETE CAUSE OF DEATH?
<br />o Not pregnant, but prognant 43 days to 1 year before death o Other (Sp.clly) oVES oNO
<br />"tl OUnknown If pregn.nt within the pa5t year
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<br />a. I 22b. TIMI! OF INJURV 1 22c, PLACE OF INJURY.At homa, lot"" .troot, '.ctory, omco building, .0n.tnJctlon .It., atc. (Sp.clfy)
<br /> E 22.. DATE OF INJURV (Mo., D.y, Vr.)
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<br />CD 22d. INJURY AT WORK? /22" DESCRIBE HOW INJURV OCCURRED
<br /> 0
<br />l- OVES oNO
<br /> 221. LOCATION OF INJURY" STRI!ET & NUMBER, APT. NO. CITYfTOWN STATI! ZIP CODE
<br /> 23.. DATE OF DEATH (Mo., Day, Yr.) ~~~ 24a. DATE SIGNED (Mo.. Day, Vr.) 24b. TIME OF DEATH
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<br /> ~~ M''''''''h 1 r.: ?nnR m
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<br /> li~> 23b. DATI! SIGNED (Mo., Day. Vr.) 1.23c, TIMIWF DEATH ) ~~ >- 24c. PRONOUNCED DEAD (Mo., D.y, Vr,) 24d. TIME PRONOUNCED DEAD
<br /> <l.o....J March 17, 2008 5: 20 p. <I. 0.. 0( ..J
<br /> ~ g>~ m ~ <Il~ ~ m
<br /> <>.- 23d. To tho b..t of my .'!.no~dg~ occurr.d .1 the limo, d... and pl.c. 24&. On the baal. of examination and/or Inveatlgatlon, In my opinion d.ath occurred
<br /> ...., i I:)
<br /> '" c .nd due to tho d. ( gn.tur. ond Tltio) al th. 11m., dolO and pl... .nd duo to tha cauaol.) .tated. (Slgn.tura and Till.)
<br /> ~~ ~, - 02iO
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<br /> 25. DID TOilAcco USE CONTRIBUTE TO THE DEATH? /280, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? I 28b. WAS CONSENT GRANTED?
<br /> DYeS Iil NO 0 PROBABL V 0 UNKNOWN oVES ill NO Not Appll.able If 26. I. NO 0 YES ONO
<br /> 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHVSICIAN, CORONER'S PHVSICIAN OR COUNTY ATTORNEV) (Typ. or Print)
<br /> Dr Jane A McDonald MD 800 Alpha Gt"and Island, NE 68803
<br /> 28., REGISTRAR'S SIGNATURE M~~J1~J. {~lI 2Sb. DATE FILeD BY REGISTRAR (Mo., Day, Yr.)
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<br /> MAR 19 2008
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