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<br />STATE OF NEBRASKA
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<br />:\
<br />~~
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<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 NEBRASKA DEPARTMENT OF HEAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITIM=..Il.EC()/iWS, .
<br />
<br />DATE OF ISSUANCE.:~'~... \ ~:~~~
<br />
<br />,srA.NLEY'#:",,>.JIIJ. ."....-:'. '
<br />.-A~ip"tA,N'fI~~~ rPFt~r:;lstIMR,
<br />b€!. ~4R.." .7i. ~f?T. OF.. H. Ii.. ...)11... L TH'.ANIi
<br />LINCOLN, NEBRASKA H.u'M.,.AN iEf21,C,i.f.:." : ~~; :
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMANSiVlPES .._J.e :".--..1 :....;:.-
<br />L~KllrICATE OF U"'A t"I~; ',.. 0828'1E2
<br />2.SIO)( ";. ",I... q..AA1&~IIlll.o"llIIY,Vr.)
<br />... ("-, . '-' j. ~l ~ .. '..' . ~ ..... ""\ ........,
<br />Male '.) .:~. :f\;u<Jus,t~~l'4..;- 2008
<br />
<br />6<:. UNDIOR roAV 8~1)Ant dF BJ!lTH(Mo., Day, Vr.)
<br />HOURS I MINS.
<br />
<br />September 9, 1945
<br />
<br />SEP 0 Z 2008
<br />
<br />200807848
<br />
<br />1.DlOceDIONrS-NAMIO (First,
<br />
<br />Mlddl.,
<br />
<br />La.~
<br />
<br />Sutllx)
<br />
<br />Gerald Dean Hibbeler
<br />
<br />4. CITY AND STATIO OR TeRRlTORV, OR FOReiGN COUNTRV OF BIRTH
<br />
<br />Go. AGIO.Loot Blrthdoy
<br />
<br />Hastings, Nebraska
<br />7. SOCIAL SeCURITY NUMBeR
<br />
<br />62
<br />
<br />Gb. UNDeR 1 VeAR
<br />MOS. I' DAVS
<br />
<br />(Vrs.)
<br />
<br />506-62-1456
<br />
<br />8a. PLAce OF DeATH
<br />tlQSelIA!.i 0 Inpollont
<br />o eR/Ouipall.nt
<br />oOOA
<br />
<br />QIIW3;. 0 Nursing HomoJ~ TC
<br />iii D..,odonro Hom.
<br />o Oth.r(Sp.clly)
<br />
<br />o Hospic. Foclllty
<br />
<br />81>. FACI~ITY-NAMIO (II not Inotitution, glv. .Irs.t on~ numbor)
<br />
<br />2530 W. Lamar Ave
<br />
<br />8c. CITY OR TOWN OF DeATH (Inclu~. Zip Co~.)
<br />Grand Island 68803
<br />
<br />18d. COUNTY OF DeATH
<br />Hall
<br />
<br />9a. RESlDENCE-STATE \9b. COUNTY 19c. CITY OR TOWN
<br />
<br />Nebraska Hall Grand Island
<br />
<br />9~. STREET AND NUMBIOR 19.. APT. NO. 191. ZIP CODe
<br />
<br />2530 W. Lamar Ave I 68803
<br />
<br />10.. MARITAL STATUS AT TIMe OF DeATH IiIMarrt.d 0 Nev.r Marrtodll0b. NAMIO OF SPOUSIO IFlra~ Mlddl., La.t, sumx) Ifwll., glvo IMldon nomo.
<br />
<br />o Marrt.~, but ..poratod 0 Wldowod 0 Dlvorc.d 0 Un~nown I Elaine Schlachter
<br />
<br />11. FATHER'S.NAME (First, Mlddl., Los~ Suffix) 112. MOTHeR'S.NAMIO (Flra~ Mlddl., Mald.n Sumamo)
<br />
<br />Oscar Hibbeler Anke Marie Dudden
<br />
<br />13. eveR IN U.S. ARMel! FORCIOS? 01.0 doto. 01 ....lc.II V... I 14a. INFORMANT.NAMIO
<br />
<br />(v... No. or Un~.) Yes 05/09/1968.12/18/1969 I Elaine Hibbeler
<br />
<br />15. METHOD OF DISPOsmON 16a. e~'!iMeR-SIGNATU~ ___ I ^ n .
<br />
<br />!iilBuola' OOo..."e.. /7V)./I,""))-. ) .c--.."-----:J. UULJr(
<br />OCl1IlIIiItlor'l OEntombm.nt :';' /. eJ.r:
<br />OR.me.ol OOtn.~Bpoc'fy) -'l8d. CE,.ETERV, CRIOMATORY OR OTHeR LOCATION
<br />
<br />S1. Paul's Lutheran Cemetery
<br />
<br />199. INSIDe CITY LIMITS
<br />I&l Vos 0 No
<br />
<br />14b. RELATIONSHIP TO DEceDENT
<br />
<br />Wife
<br />
<br />I 18b.LIC?59'7
<br />
<br />16c. DATe (Mo., Day, Vr.)
<br />
<br />AUQust19,2008
<br />
<br />CITYITOWN
<br />
<br />STATe
<br />
<br />GIBnvil
<br />
<br />Nebraska
<br />17b. Zip Cod.
<br />68801
<br />
<br />170. FUNeRAL HOMe NAME AND MAILING ADDRess (Str..~ City or Town, St.to)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />
<br />CAUSE OF DEATH (See instructions and examDles)
<br />
<br />11. PARr I. Enter U" t:lulln of iWfmtlf . dl........ Injlu111*1 at compllc:atio".~ that dlredly clu..d the death. DO NOT .mer te""I~1 pt!Il1ta luch .. catdiac a.....It,
<br />n1lpil'totol'y am.I, Of yenttlcular flbrUlatlon without .howlng the eUology. DO NOr ABBREVIATE. Em.' only on. t:..ua on a Ilnil. Add additl<malllne. tf nee.lllry.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />IMMEDIATIO CAUSE (Fino!
<br />dlseaso or condition ,"ultlng al
<br />In dtIoth)
<br />
<br />natural causes related to old age
<br />
<br />"I" APPROXIMATe INTeRVAL
<br />I
<br />on.et to d.alh
<br />I
<br />
<br />I unknown
<br />
<br />DUE TO, OR AS A CONSeQUeNCe OF:
<br />
<br />on..t to d..th
<br />I
<br />
<br />I
<br />
<br />Soquonti.lly lI.t condition.. If b)
<br />l!IIny, le.dlng to the cause listed
<br />on IIn. a.
<br />
<br />Due TO, OR AS A CONSEQUENCIO OF:
<br />
<br />onl.t tD death
<br />I
<br />
<br />I
<br />
<br />Enlor tho UNDIOR~ VINe CAUSE c)
<br />(dl..... or Injury that Inltlotod
<br />the .v.nt. re.ulting In d.olh) DUE TO, OR AS A CONSeQUeNCe OF:
<br />LAST
<br />
<br />d)
<br />
<br />on..t to d.ath
<br />I
<br />I
<br />I
<br />18. WAS MeDICAL eXAMINeR
<br />OR CORONER CONTACTED?
<br />
<br />Iii ves 0 NO
<br />
<br />18. PART II. OTHeR SIGNIFICANT CONDITIONS.condltlon. contrlbutlng 10 Iho doolh but not resullln91n tho undorlylng c.uso given In PART I.
<br />
<br />a::
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<br />u:
<br />~
<br />ffi
<br />CJ
<br />A'
<br />~
<br />Q.
<br />~
<br />CJ
<br />Gl
<br />III
<br />~
<br />
<br />20. IF FIOMA~IO:
<br />o Not pregnant within poot yoar
<br />o Pregnant at 11m. 01 death
<br />o Not praynant, but pregnant within 42 day. 01 doolh
<br />o Not pregnant, but preliiln.nt 43 day. to 1 ye.r before death
<br />oUnMown II praynont within the pa.t y.ar
<br />
<br />210. MANNeR OF DeATH
<br />liB Natural 0 Homlcldo
<br />o Accld.nt 0 P.ndlng In.ootlgotlon
<br />o Sulcld. 0 COuld not b. d.t.nntn.d
<br />
<br />21b. IF TRANSPORTATION INJURV
<br />o Drlv.r/Op.rator
<br />o pao..ng.r
<br />o 'Pedestrian
<br />o Olhor (Spoclfy)
<br />
<br />21c. WAS AN AUTOPSV PERFORMED?
<br />DYES UNO
<br />
<br />21d. WeRe AUTOPSV FINDINGS AVAlLAB~E
<br />TO COMP~ETE CAUSE OF DeATH?
<br />
<br />oVES I!l[NO
<br />
<br />l22b. TIME OF INJURV T 22c. PLACE OF INJURV-At homo, fonn, otr<lOt, I.ctory. otIlc. building, construction .It., etc. (Sp.clly)
<br />
<br />
<br />2Jol.lNJURY AT WORK? 228. DiSCRIBE IfOW INJURV OCCUMl;D
<br />
<br />DYES oNO
<br />
<br />22a. DATe OF INJURV (Mo., Doy, Vr.)
<br />
<br />221. LOCATION OF INJURV - STReeT & NUMBeR, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP cooe
<br />
<br />z
<br />!'S;
<br />o
<br />i~>-
<br />~"-:i
<br />8~O
<br />.."
<br />,I:lC
<br />~i
<br />
<br />24a, DATE SIGNED (Mo., D.y, Vr.) 24b. TIME OF DeATH
<br />
<br />!'~~ AUQust 27, 2008 Au<mst 14. 2008 at 10:00 m
<br />-Q::
<br />I ~ ~ >- 24c. PRONOUNceD OeAD (Mo" Day, Vr.) 24d. TIME PRONOUNCED DeAD
<br />
<br />~~c:i August 15, 2008 10:26 am
<br />
<br />8 ffi ~ 0 2.4~ n the b..I. of exarnlm-:"j1ln .nd/or In\feellgatlon, In my opinion death oticurred
<br />11 ~ 5 I tho /J"1'J~oto 5d ~.c nd due to the cauoo(o) stotod. (Slynoture and Tlti.)
<br />
<br />~ ~ ~ 1.4i/ "r Deputy Hall
<br />o 0 ~ Countv
<br />
<br />25. DID TOBACCO use CONTRIBUTE TO THE DeATH? 1 28a. HAS ORGAN OR TISSUE DONATION B eN CONSIDEReD? II }5b. WAS CONseNT GRANTeD?
<br />o ves 0 NO 0 PROBAB~ V IiJUNKNOWN 0 VES ~ NO ' T Not Appllcablo II 260 Is NO 0 YES 0 NO
<br />
<br />2? NAME, TITLE AND ADDRess OF CERTIFieR (PHV5ICIAN, CORONER'S PHVSICIAN OR COUNTY ATTORNIOY) (Typ. or Prlnt)
<br />
<br />23b. DATe SIGNED (Mo.. Doy, Yr.)
<br />
<br />1 23c. TIMe OF DeATH
<br />
<br />m
<br />
<br />231. DATE OF DeATH (Mo.. Doy, Vr.)
<br />
<br />23d. To the be.t of my knowledge, d..th occu.....d .t the time. date and pl.-c.
<br />ond duo to the causo(.) .tated. (Slgnolure ond TIllo)
<br />
<br />Jack Zitterkopf, Deputy Hall
<br />260. ReGISTRAR'S SIGNATURE
<br />
<br />County Attorney, 231 S. Locust
<br />
<br />,~..~ 1. ~
<br />y
<br />
<br />Street
<br />
<br />Grand Island NE 68801
<br />28b. DATe FILeD BV REGISTRAR (Mo., Doy, Yr.)
<br />
<br />p
<br />\~
<br />
<br />AUG 28 2008
<br />
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