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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL TH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEB~'Jt7!/i~"":R.'fi'<lENT OF HEAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITOR~:r:tf'< ~~~:~~~jl >
<br />
<br />DATE OF ISSUANCE ,,~A1~~'.~
<br />2 0 0 8 0 7 8 4 4 : ."STANLEY F;,.r:;QOPER ',~- i,
<br />AUG 15 20' :_,)4PSI~mSJAr.E'RE61%TriAR
<br />:~PA. f 'w.. 'F1HfAqFf~AN..D
<br />LINCOLN, NEBRASKA ' ~ HUMA. . ttrtts '"-. I
<br />. / ~;,)~, .', '.'.,.', : (~.') ~.o'
<br />
<br /> ,..., STATE OF NEBRASKA . OEPART~~~ ~;~~~ AND HUMA~',S~lC(sf:- 511 ,gt';~~ '2 M~b 7
<br /> CERTIFIC TH "., ". .'. '
<br /> ~ 1.0eCIOOeNr8-NAMe (First Mlddlo, Loot Suffix) 2. sex ' " 't_ ~"T~ ~".~:l1lJofo..o"Y,Yr.)
<br /> , '
<br /> Clarence Frank Gust Peter Male -. .4.-1.!gys1. '&. ~008
<br /> 4. CITY AND STATe OR TeRRITORV, OR FOReiGN COUNTRY OF BIRTH So. AGe-L...t Blrthd.y 5b. UN~eR 1 VeAR Se. UNDER 1 DAV S. DATE DF BIRTH (MD., Doy, Vr.)
<br /> (Yrs.) MOS. I DAVS HOURS I MINS.
<br /> Hadar, Nebraska 84 July 11, 1924
<br /> 7. SOCIAL SECURITY NUMBER So. PLACE OF DeATH
<br /> 508-12-3133 ~ 0 InpoUent ml:LEB;.l8I Nursing HomeIL TC D Hooplco F.clllty
<br /> Ub. FACILlTY-NAIIIE (If not InoUlullon, give olr.oland numb.r) o eR/Outp.".nt o Deced.nr. HOlM
<br />"'- 1 o DOA o Other(Spoclfy)
<br /> Tiffany Square Care Center
<br /> ..J 8c. CITY OR TOWN OF DEATH (lnt:ludo Zip Cod.) lid. COUNTY OF DEATH
<br /> i:! Grand Island 68803 Hall
<br /> w
<br /> z I.. ReSIDENCE-STATE lIb. COUNTY /Ie. CITY OR TOWN
<br /> ;;)
<br /> II.
<br /> j Nebraska Hall Grand Island
<br /> -g 1<1. STREET ANO NUMBER Iuo. APT. NO. I'" ZIP CODE lis. INSIOe CITY LIMITS
<br /> .! 2 Chantilly Street 68803 IKI Yo 0 No
<br /> 'C
<br /> . 10e. MARITAL STATUS AT TIME OF OeATH iii M.n1ed ON.... Man1adll0b. NAME OF SPOUSE (First, Mlddl., Loot, Suffix) If wil., gl.. molden nomo.
<br /> ~ D M.n1od, but aep..ated D WldDWOd o Divorced D Un~nown June Ann Ballantyne
<br /> .
<br /> i5. 11. FATHeR'S-NAME (First, Middle, sumx) 112. MOTHER'S-NAMe (F1rs~ Mlddl.. Malden Sum.m.)
<br /> E L..t,
<br /> 0
<br /> U Otto Peter Bertha Warneke
<br /> ~ 13. EVER IN U.S. ARMED FORCEU? GI.. dot.a DI..rvle. II veo'l 140.INFORIIIANT-NAME 14b. RELATIONSHIP TO DIOCEDENT
<br /> ~ (V.., No,orUn~.) Yes 07/27/1943-01/03/1946 June Ann Peter Spouse
<br /> lS. METHOD OF DISPOSITION 1Sot\;;;;;I{lj);& /' A/7 J ~ I 1Gb. LICENse NO. lSc. DATe (MD., D.y, Yr.)
<br /> IiISUrIa' ODoJUltton /(J7/ Auaust 11, 2008
<br /> Dc.......'.. o entombment 16d. CEMETERY, CREMATORV OR OTHER L~ON CITYfTOWN STATE
<br /> D R......I O"""~apo.Ify'
<br /> Grand Island City ElslI,tsPf Cemetery Grand Island Nebraska
<br /> 170. FUNERAL HOME NAME AND MAILING ADORESS(Strsat. City Dr Town, State) 17b. Zip Cod.
<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 tnI ch.ln of IWMU -It........ Injurtes, or eomptle.tlon.~ tnat dll'el:t1y cau.lld th" de.. 00 NOT .nler annln.' .....0.. such .. CIIrdl.c _rTQt, I APPROXIMATE
<br /> INTERVAL
<br /> ".plmOI'y amtt, or YIIntrlcular flbrtllftlon wlt~~t ..nowina tn. ~I010~y. DO NOT ABBREVIATE. &pt"r ani)' an. ClU.. on . liM. Add addhlonalllne. If ""Ce_Bal')'_ I
<br /> IMMEDIATE CAUSE, onset to delth
<br /> IMMEDIATE CAUSe (Fln.1 ~4{uM.l. I
<br /> dI..... or condltton ....ulUng 0) ~gllt-),~ ...,. I J tlJU ;::.f
<br /> In d.oth)
<br /> DUE TO, OR AS A CONSEQUENCE OF: onaat to doath
<br /> I
<br /> S.qu.nU.lly lIat eondlllono, II b) ~_(J PI) I /OYAS
<br /> any, leading to the eau..n.t.d
<br /> on IIn. .. DUE TO, OR AS A CONSEQUENCE OF: onaat to death
<br /> I
<br /> Entor tho UNDERL VING CAUSE el I
<br /> (dla..ae Dr Injury that Inlllotod DUE TO, OR AS A CONSEQUIONCE OF: onoot to d.ath
<br /> tho a..nlo rsoultlng In dooth)
<br /> LAST I
<br /> I
<br /> dl I
<br /> lS. PART II. OTHER SIGNIFICANT CONOITlONS-Condltlono contributing to tho d..th bu' not roaulUng In the und.rlylng c.u.. gl..n In PART I. 11. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> D VES 1240
<br /> a::
<br /> w 20. IF FEMALE: 210. MANNER OF DEATH 21b.IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> u::
<br /> ~ o Not pregnant within past year o N.tursl o Homlcld. a DrI.orlOporstor OVES ql;rlo
<br /> W o prsgnant at Um. '" d.oth D Accld.nt D P.ndlng In..aUgIUon D P....ng.r 21d. WERE AUTOPSY FINOINGS AVAILABLIO
<br /> U o Not p...gnont, but prlgnont within 42 daya 01 d.oth o Sulcld. a Could not be d.t.rmlned o Pedntrtan TO COMPLETE CAUSE OF DeATH?
<br /> j o Not pregn.nt but pregn8nt 43 days to 1 y.ar b.to... d.ath o Oth.r (Specify) DVES ANO
<br /> ~ DUn~nown If prognant within tho p..t ya.r
<br /> O!
<br /> i5. I 22b. TIME OF INJURV 1 22c. PLACE OF INJURY-At homo,l.rm, .trsot, Ioctory, DIlle. building. eon.truetlon olto, .tc. (Specify)
<br /> g 22a. OATE OF INJURV (Mo.. O.Y, Yr.)
<br /> U
<br />-- . - .-
<br /> .lD 22d.lIUUftY AT WORk? : 2ai....ItllW1liiLQW~..D ~..~ '~ :~ :.:.,:, .. l :.."'". , .\.:.....".. ) -. -- --~-- -' - -,-
<br /> {l ",.J" -~ ~ ?" "'"
<br /> DYES DNa
<br /> 221. LOCATION OF INJURV - STREET" NUIIIBER. APT. NO. CITYfTOYIIN STATE ZIP CODE
<br /> 230. DATe OF OeATH (MD., OIY, Vr.) Z 240. DATE SIGNED (11I0., O.y, Yr.) 24b. TIME OF DeATH
<br /> ...~ August 6, 2008 1;~1 m
<br /> .ou
<br /> J~>- 23b. DATE SlGNeO (MD., O.y, Yr.) /23C' TIME OF DEATH ~ ~~ >- 24e. PRONOUNCEO DEAD (Mo., O.y, Yr.1 24d. TIME PRONOUNCED OeAD
<br /> ~D. 2! g-~t-or 9: 50 pm i!iD.-r;...j m
<br /> 8 g'o :lad. To th:~~, ~nDWlodgo do.th occurrsd .t tho tlmo, d.t. ond pllce ~ ~~ ~ 24.. On tha boala DlaXlmlnodon Indlor In..ollgotlon, In my opinion d.oth oecurrsd
<br /> 11"" and dU., /_ clua~: at ;:rnrR.nd TItle) "Z::J at tho 11m., dot. ond pile. ond due to the eouaa(a) ototed. (Slgn.turs .nd TlU.)
<br /> ~j "'00
<br /> ~l!S~
<br /> 00
<br /> 25,; TOBACCO USE CONTRIBUTE TO THE OeATH? 1261. HAS ORGAN OR TISSUE OONATION 8EEN CONSIDEREO? 1211>. WAS CONSENT GRANTEO?
<br /> 'l'ES D NO D PROBABLY 0 UNKNOWN o VES ~O Not Appllcabl. If 2So 10 NO 0 VES..at" NO
<br /> 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHVSlCIAN. CORONER'S PHVSICIAN OR COUNTY ATIORNEY) (Typa Dr Print) ,
<br /> David R. Colan, MD, 729 N. Custer AVe. , Grand Island, NE 68803
<br /> 2SI. REGISTRAR'S SIGNATURE ..1tAMt J ( ~llht 26b. DATE FILED BY REGISTRAR (11I0.. O.Y. Yr.)
<br /> p AUG 1 3 2008
<br /> -,,.- ' 'wit '"
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