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<br /> . O.8-.g "37
<br />"\ CERTIFICATE OF DEATH -. .~
<br />~ 1. DECEDENT'S-NAME (FI..I. Middle. Laet, Suffix) 2. SEX ,. . : ~'~TE'pP D~"M lMtj:;o.y,Yr,)
<br /> ."
<br />Lloyd Christopher Ehlers Male. Aprjl tl',iQW-~
<br />] 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE.Leal Blnhdey lb. UNDER 1 YEAR Sc. UNDER 1 DAY 5. I,')A1"1;; Of'eIRTH (Mo., Dey, Yr.)
<br /> (Yre.) MOS. I DAYS HOURS I MINS.
<br />Hall County, Nebraska 91 January 3,1917
<br />~ 7. SOCIAL SECURITY NUMBER I.. PLACE OF DEATH
<br />508-18-9440 ~ 0 Inpallent Q!I:Wt IXI N....lng Home/L TC o Ho'plce F.cllity
<br />lb. FACILITY-NAIIIE (If nollnalll..llon, glv. .Ireel.nd n..rnber) o ERIOu1p.II.nt o Decedenl'. Home
<br />~ Park Place-A Golden Living Center ODOA o Olh.rjSpecJfy)
<br />,~ ec, CITY OR TOWN OF DEATH (Incl..d. Zip CQd.) I ed. COUNTY OF DEATH
<br />W Grand Island 68803 Hall
<br />z ea, RESIDENCE-STATE I eb. COUNTY Tec. CITY OR TOWN
<br />it
<br />~ Nebraska Hall Grand Island
<br />a: ed. STREET AND NUMBER 19.. APT. NO. IUf. ZIP CODE leg. INSIDE CITY UMITS
<br />l;: 6462 North Gunbarrel Road 68801 o Yea IX! No
<br />'5;
<br />C!: lOa. MARITAL STATUS AT TIME OF DEATH o Marrlad IXI N.ver M.rriodll0b. NAME OF SPOUSE (FI"L Middle, La.I, S..lIIx) If wlf., glv. maiden n.rne.
<br />1:1 o M.rrled. b..1 .epe..l.d 0 Widowed o Divorced o Unknown
<br />!
<br />Q. 11. FATHER'S.NAME (FI"I, Middle, Leel, s..mo) 112. MOTHER'S-NAME (FlreL Middle, M.ld.n S..rn.rne)
<br />8
<br />u John William Ehlers Marie Augusta Wiegert
<br />ell 14b. RELATIONSHIP TO DECEDENT
<br />CD 13. EVER IN U,S. ARMED FORCES? Giv. da"'" oheNlce lfye.'ll4a.INFORMANT-NAME
<br />0 (Ya.. No. or Unk.) No Ruth CloUllh Power of Attornev
<br />I-
<br /> 15. METHOD OF DISPOSITION 16a. E'(iz:r,r;/h~ fu I 16b. LICENSE NO. 16c, DATE (Mo., D.y, Yr.)
<br /> [ilBon., DConBtlon /1'11 April 9, 2008
<br /> o C,.m.tlon o Entombmllm lId. CEMETERY. CR(MATORY O~ LOCATION STATE
<br /> o Remov4l1 o OIhenS"'<'''1 CITYITOWN
<br /> WiegBrt Cemetery Grand Island Nebraska
<br /> 17s. FUNERAL HOME NAME AND MAILING ADDRESS (SIreel, City or Town, Slale) 17b. Zip Code
<br /> Livingston-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 68803
<br /> CAUSE OF DEATH (See instructions and examples)
<br /> 11. PIJtT I. Enter tn. eh.ln 0' evedb 7 dl,""s, InJul1e., or compllcation8- that dll1tctly csu",d the d..th. DO NOT enter tBflOlmll eventlsuch U clrdlae al'l'l8l:, 1 APPROXIMATE
<br /> INTERVAL
<br /> ,"Plrltory IlYut, or v4tDtrie;ular f1brUlstlo" wlttlaU'$howlna tn. etiOlogy. DO NOT ABBREVIATE_ I:.l'ller only on. g,UA on sl108. Add sddIUc:u,..llln.. if Me4I..aty. 1
<br /> IMMEDIATE CAUSE: I onset to death
<br /> IMMEDIATE CAUSE (Fln.1 t?(..V~.).,) 1'<\ (:) ~ ,~ 1
<br /> dls.... or Condition resulting ay :r: ~~,,"\~S
<br /> In de.lh)
<br /> DUE TO. OR AS A CONSEQUENCE OF: I Onaet to death
<br /> 1)0
<br /> Seq..enll.lly 11.1 condllion., If ~ 1
<br /> I
<br /> any, lellldlng to the cause lI_ted I
<br /> on IIn. a. DUE TO, OR AS A CONSEQUENCE OF: , on.et 10 d..th
<br /> I
<br /> I
<br /> Enler Ihe UNDERLYING CAUSE c) I
<br /> (dl..... or inj..ry th.llnllialed I
<br /> the evenl. re...lllng In de.th) DUE TO, OR AS A CONSEQUENCE OF: I on..t to death
<br /> LAST ,
<br /> 1
<br /> 1
<br /> d) 1
<br /> ~ART II. OTHER SIGNIFICANT CONDITIONS-Condllion. ctmlrib..ling 10 tha de.th b..1 nol re...lllng in the ..ndarlylng c..... given In PART I. 111. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> N~,...,)€.. DYES S NO
<br />0:::
<br />W 20, IF FEMALE: ~.. MANNER OF DEATH 21b.IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />u:
<br />~ o Nol pregnant wllhin pe.1 year 9.,Nal..ral 0 Homicide o Driv.r/Op.rator Dyes aNO
<br />W o Pregn.nl .1 lime of de.lh o Accldanl 0 Pending Invoellg""on o pea.enger 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />U o NOI pregnanL but pregn.n. within 42 d.ya of deeth o Suicide o Co..ld nol be datermlned o Pad.strlan
<br />~ TO COMPLETE CAUSE OF DEATH?
<br />o NOI pregnenl, but pregn"nl43 d.y. 10 1 yeer before dealh o Other (Specify) DYES Vi NO
<br />1:1 OUnknown If pregnanl within the p..t ye.r
<br />!
<br />Q. I 22b. TIME OF INJURY 1 22c. PLACE OF INJURY....I horne, form. .lreeL faclory, oIIIce building. con'l...cllon .lle, ale. (Specify)
<br />E 228. DATE OF INJURY (Mo.. D.y, Yr.)
<br />0
<br />U
<br />.z 22d; INJURY AT WORK? 22e. DESCRIBE HOW IN.JURY OCCURRED-' - .'~. -- - -- ~--
<br />~ DYES ONO
<br /> 221. LOCATION OF INJURY. STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP COOE
<br /> ~. DATE OF DEATH (Mo., Dey, Yr.) ~~i::i 24.0. DATE SIGNED (Mo., D.y, Yr.) ~. TIME OF DEATH
<br /> Z 0'\ - C~- O~
<br /> ~:5 m
<br /> It. 2~
<br /> ~. DATE SIGNED (Mo., Dey. Yr.) 12~c~se r'o 240. PRONOUNCED DEAD (Mo., D.y, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> 0'\.... O~ - O~ -!;;=:>-
<br /> Eo....J m "" 0.. 0( ... m
<br /> 8 g'~ E 1Il~ Z
<br /> ~ To the best of my knOwledge. dellth occurred at the time, date and plllce 811:: 0 24e. On the busi. of examination and/or Investigation, In my opinion death occurred
<br /> Z:g ~ee(.) .laled.(Slgnature and TIlle) II ~~ elthe time, dale .nd pl.ce .nd due 10 th. c....e(.) slaled. (Slgn.l..re and Tille)
<br /> o~ 000
<br /> 0( ~ . \v-.. C't ~"'\ c... \ \"l.. ~ ~ ... tl::(,l
<br /> 0,-
<br />....". (,l0
<br />~ ~ID TOBACCO USE CONTRIBUTE TO THE DEATH? l,.sa. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? .1 )C&. WAS CONSENT GRANTED?
<br /> o YES ~ 0 PROBABLY 0 UNKNOWN DYES lll.NO Nol Appllcabl. If 21" I. NO 0 YES ~O
<br /> 'laCNAME TITLE AND ADDRESS OF CERTIFIER (PHYSIC~CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ. or Prinl)
<br /> John Cannella. M.D.. 729 N Custer Grand V~.l and. NE 68803
<br /> 28a, REGISTRAR'S SIGNATURE ~~',/~ A7~ 28b. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />p L '. VVVf"'w APR 1 0 2008
<br /> ,-.... ~ll
<br /> V
<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 RECORP,QfJ FILE. WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSTIC~ ~T1.?tt WHlj:H IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS'I1I'~At~2~t'~k:: '...,
<br />
<br />DATE OF ISSUANCE 20 0 80 7 4 4 6 }V~~74~f::~y s. c6bj;~ic~
<br />
<br />L~:~L~ ;E;2~:KA H~i~~~15 / '
<br />
<br />~,. I . '-.....
<br />STATE OF NEBRASKA DEPARTMENT OF HEALTH AND HUMAN ~YI~S '$1
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