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<br />1, DECEDENT'S-NAME (First,
<br />Elmer
<br />
<br />STATE OF NEBRASKA
<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, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _AI'..br ..&M ...... 'iilc:':""~
<br />
<br />DATE OF ISSUANCE JJ'''''''' "~NJi'i$~OPER
<br />
<br />~~~~.~E~~:KA 20080696 8 ~4ru~~~.
<br />
<br />. ~; "'::~ "y ",":~)~~
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER\IlCt;S FINA~E .. ,
<br />CERTIFICATE OF DEATH :_', '-, '
<br />- r 2~$ii1' .I'\I'"~
<br />. M'aj:~~":"
<br />
<br />5c,,"UNDER lDA",~ B,DATE OF BIRTH (Mo" Day, Yr.)
<br />HOURS 'MfN8,
<br />
<br />
<br />607
<br />
<br />("l
<br />
<br />
<br />Middla,
<br />Henry
<br />
<br />Last,
<br />Uhrich
<br />
<br />Suffl.)
<br />
<br />'3,~tE OF DEATH (Mo" Day, Yr.)
<br />,~October 27. 2007
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Lincoln. Nebraska
<br />
<br />5a, AGE-Last Birthday 5b, UNDER I YEAR
<br />(Yrs,) MOS, DAYS
<br />88
<br />
<br />June 21. 1919
<br />
<br />?, SOCIAL SECURITY NUMBER
<br />507-24-4670
<br />
<br />Ba, PLACE OF DEATH
<br />l::l.Q.SEilAl.: D Inpatient
<br />
<br />Bb, FACILlTY.NAME (If not institution, give street .nd number)
<br />
<br />D ERlOutpallent
<br />
<br />QIlJf8: D Nursing Home/LTC D Hosplca Facility
<br />
<br />Xl Decadant's Home
<br />
<br />Home:
<br />
<br />7287 South 130th Rd.
<br />
<br />Be, CITY OR TOWN OF DEATH (Includa Zip Coda)
<br />Wood River
<br />
<br />68883
<br />
<br />D coo. D Other (Specify)
<br />
<br />Bd, COUNTY OF DEATH
<br />Hall
<br />
<br />9., RESIDENCE.STATE
<br />Nebraska
<br />
<br />9b, COUNTY
<br />Hall
<br />
<br />
<br />91, ZIP CODE
<br />68883
<br />
<br />9g, INSIDE CITY LIMITS
<br />DYES 1fI NO
<br />
<br />9d, STREET AND NUMBER
<br />7287 South 130th Rd.
<br />
<br />lOa, MARITAL STATUS AT TIME OF DEATH IllI Married D Naver M.rried lOb, NAME OF SPOUSE (First, Middle, Last, Sulflx) II wile, 9ive maiden name,
<br />
<br />D Married, but separated D Widowed D Divorced D Unknown Alice Layher
<br />
<br />11, FATHER'S-NAME (First,
<br />Henry
<br />
<br />Middle,
<br />J.
<br />
<br />Lest,
<br />Uhrich
<br />
<br />SUffix)
<br />
<br />12, MOTHER'S.NAME (First,
<br />Mary
<br />
<br />Middle,
<br />Ann
<br />
<br />Maidan Surneme)
<br />Amen
<br />
<br />13, EVER IN U,S, ARMED FORCES? Glv. d.t.s of servlcalf y.., 14a, INFORMANT-NAME
<br />(Yes,no,orunk,) No Alice Uhrich
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />15, METHOD OF DISPOSITION
<br />D Burial D DonatiOn
<br />
<br />r:xcremetion D Entombment
<br />
<br />lSa, EMBALMER-SIGNATURE
<br />Not Embalmed
<br />
<br />lSd, CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />lSb, LICENSE NO,
<br />
<br />CITY / TOWN
<br />
<br />16C, DATE (Mo" Day, Yr, )
<br />October 29. 2007
<br />
<br />STATE
<br />
<br />D Removal D Oth.r (Sp.city)
<br />
<br />Westlawn Memorial Park ~rematory Grand Island.
<br />
<br />I?, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, St.te)
<br />Apfel Funeral Home. 1123 West Second.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onset to death
<br />
<br />IMMEDIATE CAU6E (Final
<br />dl_oe or condltlon reeultlng
<br />in death)
<br />
<br />(a) ~\ iM.\\ t. Cftl\c.eJI\... _
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />
<br />VV'\~
<br />
<br />Sequ.nll.lly 1111 condltlonl, ~
<br />Iny, loodlng 10 Ih. C8ueallltod
<br />on Itnea.
<br />En\arthe UNDERLYiNG CAUSE
<br />(dl_.. or Injury 'h.'lnltia\od
<br />the ..ents ....ultlng In dealh)
<br />LAST
<br />
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onsel to de.th
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />la, PART II, OTHER SIGNIFICANT CONDITIONS.Conditlons contributing to tho death but not r.sulling in the und.rlyfng cause given in PART I.
<br />
<br />\) f\\ tM\f\l\ ~~~ 6..\ t V't\f\."\:uk cN.-~ l l. ~
<br />
<br />22d, INJURY AT WORK?
<br />
<br />
<br />21d, WERE AUTOPSYFINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES D NO .
<br />~OF'INJUAY'AI home,larm, street, factory, office building, construction sll., .to, (Speclly)
<br />
<br />21b, IF TRANSPORTATION INJURY
<br />D Driver/Operator
<br />
<br />CI P....nger
<br />
<br />D P.destrian
<br />
<br />D Other (Speclty)
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />DYES JQ NO
<br />21c, WAS AN AUTOPSY PERFORMED?
<br />
<br />20, IF FEMALE:
<br />D Not pregnent wllhin past year
<br />D pregn.nt.t time 01 death
<br />D Not pr.gnant, but pregnent within 42 dsys 01 death
<br />D Not pregnent, but pregnant 43 days to 1 year before daath
<br />DUnknown If pregnant within fhe p.st year
<br />~I, DATE OF INJURY
<br />N
<br />
<br />21a, MANNER OF DEATH
<br />~stural D Homicide
<br />
<br />D AccldentD Pending Inveallg.llon
<br />
<br />D Suicide D Could not be determined
<br />
<br />DYES
<br />
<br />)(NO
<br />
<br />m
<br />
<br />DYES CI NO
<br />
<br />221, LOCATION OF INJURY. STREET & NUMBER, APT. NO,
<br />
<br />CrTYiTOWN
<br />
<br />STIlTE
<br />
<br />ZIP CODE
<br />
<br />23a, DATE OF DEATH (Mo" D.y. Yr,)
<br />\0... '2.,-tJ\
<br />
<br />24a, DATE SIGNED (Mo" Day, Yr,)
<br />
<br />24b, TIME OF DEATH
<br />
<br />~~~
<br />ut
<br />~,~~
<br />!!j!::l
<br />,2~8
<br />o ~
<br /><.> "
<br />
<br />m
<br />
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr,) 24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />248_ On the basis of examination and/or investigation, in my opinion death OCcurred at
<br />fhe 11m., date and place and duo to the cause(s) stafed, (Signature and Tltla ) ...
<br />
<br />268, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />DYES ~ D PROBABLY D UNKNOWN D YES ~O
<br />2?, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Steven Husen M.D. 2116 West Faidley Ave.. Grand
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />Not Appllcsble 112Ba Is NO DYES
<br />
<br />NO
<br />
<br />2Ba, REGISTRAR'S SIGNATURE
<br />
<br />
<br />Island. NE.
<br />
<br />68803
<br />
<br />2ab, DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />OCT 3 1 2007
<br />
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