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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANDHUMAN~/~J{fCES <br />SYSTEM, "CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL"RECOBP:-owrfCE.wu'H <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSTICSJ!I!"Qt!IJ'IJ,-'~~JS:-. <br /> <br /> <br />:J:A:ENL~:7L:;rroRYF~:A~;~~; 8 4 JY4lt/fiBt~~ <br /> <br />ASSlSTA~T:$rATE REGISTRAR.:i :'1 <br />LINCOLN, NEBRASKA HEAL TH AND HUMAN sEtMGES ,SYMEM-? j/ <br />...._".__ ....___..,_._.~_.__.,__"''''_,,___ ~'~:~., -~_~~"-=:~-=-~-~ .~r':':_,~-_ _',"~~- <br />STATE OF NElJRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICDfJR.€r.lcEJ,Nl'-~ <br />CERTI~~~~~~~EATH '-'-L ~---"~~~''"_.:;,1J 3 <br />LAST <br /> <br />00256 <br /> <br />1. DECEDENT - NAME <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />2. SEX <br /> <br />3. DATE OF DEATH IM"",h. Day. Yearl <br /> <br />Clarence <br /> <br />F <br /> <br />Obenneier <br /> <br />Male <br /> <br />January 10, 2003 <br /> <br />4;"'(:i-r'y' AND STATE OF BIRTH INfIt)/ltt VSA.. fIIImflCOUIftryl <br /> <br />Giltner, Nebraska <br /> <br />50. AGE - LGOt BIt1hdaV <br />IVrs, 78 <br /> <br />UNDER 1 VEAR <br />5b. MOS DA VS <br /> <br />UNDER 1 DAV <br />50. HOURS' MINS <br /> <br /> <br />6. DATE OF BIRTH lMonth. Day. Yoar} <br /> <br />July 30, 1924 <br /> <br />6b. FACILITY" N.me <br /> <br />IN not _ gi.. "'Nland numbor} <br /> <br />Sa, PLACE OF DEATH <br />!!.9~PITAL; 0 <br />o <br />o <br /> <br />Inpalient OTH_E~ ~ Nursing Home <br />ER o..lQaUe", 0 Residence <br />DOA 0 Other {Specl!vl <br /> <br />7. SOCIAL SECURTIV NUMBER <br /> <br />508-44-7461 <br /> <br />Nebraska/Western Iowa HCS <br /> <br /> <br />-80 CITY. -rowrfOR LOCATION OF DEATH <br /> <br />Nebraska <br /> <br />go COI)N-rY <br />Hall <br /> <br />J 6<1. . INSIOE CITY LIMITS <br /> <br />Ve. Q9 NO 0 <br />9<:. CITV. TOWN OR LOCATION <br /> <br />9<1. STREET AND NUMBER Ilncludlng ZIp Codel <br /> <br />68801 <br /> <br />.. INSIDE CITY liMITS <br />Yes [] No 0 <br /> <br />Grand Island <br /> <br />'0. RESiDENCE. STA-rE----- - - <br /> <br />10. RACE - (a.g., While:. Blacl( Al"Mlfican indian_ 111. ANCESTRY 18.g.. Italian. MelflCan. Germarl, etc.) <br />etc.IISoocilyl Whi te ISt>OC;fy1 Gennan <br /> <br />... USUAL OCCUPATION la'"" k~OI;;;;;~d(;", iiUiiii9-;;;'i-~ KIND OF BUSINESS INDUSTRV <br />ot""rl<ifIglife..vendrWe<ll Fanner <br /> <br />13. NAME OF SPOUSE (If Wife. give maiden name) <br /> <br />Lint <br /> <br />16. FATHER. NAME <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />MAIDEN SURNAME <br /> <br />(Dec) <br /> <br />Henry <br /> <br />(Dee) <br /> <br />Ida <br /> <br />Sundenneier <br /> <br />Elnora Obermeier <br /> <br />2519 Park Drive Grand Island, NE <br /> <br />2OC:T:(~Irr~08 2~:~:OF~PO::::., <br /> <br />22YFlJNERALHOME.NAMEP' Jacobsen- <br />Greenway Funeral Home 0 C,amalioo 0 Don.'"n <br />nb. FUNERAL HOME ADDRESS (STREET OR R.F.D.'NO.. CITV OR TOWN, STATE. ZIPI <br /> <br />68801 <br /> <br /> <br />2'b, DATE <br /> <br />an <br /> <br />2003 <br /> <br />STATE <br /> <br />Grand <br /> <br />Island <br /> <br />Nebraska <br /> <br />411 "0" street <br />---------- <br />2J. IMMEDIATE CAUSE <br />PART . <br />I <br /> <br />St. <br /> <br />Paul, NE 68873 <br />(ENTER ONL V ONE CAUSE PER LINE FOR Ial.lbl. AND 1011 <br /> <br />Ibl.. End,.,Stage CHF <br />DUE TO. OR AS A CONSEOUENCE OF . <br /> <br />I Inlerval Mtwean onset and d&alh <br />I <br /> <br />: Few Minutes <br /> <br />I Inrer\lal between onset and oeath <br />I <br /> <br />: Several Months <br /> <br />I Interval Mlween onset and dealt\ <br />I <br /> <br />: Several Months <br /> <br />25 WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER' <br /> <br />la, Cardiorespiratory Arrest <br />DUE TO. OR AS A CONSEOUENCE OF' <br /> <br />Icl Renal Failure <br />PART OTHER SIGNIFICANT CONDITIONS - Condllion< COnlOlbuting lolhe death bU1 no1 ,.'ated <br />" <br /> <br />260 <br />0 Accident 0 Uncletermined <br />0 Suicide 0 Pending <br />0 Homicide tnves1igation <br /> <br />26b. DATE OF INJURV IMo.. Day. Y'I 2& "OUR OF INJURV <br /> <br /> <br />269. lOCATION <br /> <br />STREET OR R.F.D. NO. <br /> <br />CITY OR TOWN <br /> <br />STATE <br /> <br />260. INJURY AT WORK <br />vooD NoD <br />270. DATE OF DEATH IMo.. Day.. Yr.J <br /> <br />260, DATE SIGNED (Mo., Q;ly, Yr.1 <br /> <br />26b TIME OF DEATH <br /> <br />January 10, 2003 <br />27b. DATE SIGNED (Mo.. Day. Yr./ <br /> <br /> <br />E" <br />l.~ ~ <br />~l~ <br /> <br />1445 <br /> <br />PM <br /> <br />;;;~ <br />Eiil~ <br />hi::>- <br />!~~~ <br />BWZ <br />1?~8 <br />8 ' <br /> <br />M <br /> <br />27c. TIME OF DEAT" <br /> <br />260. PRONOUNCED DEAD IMo Oay., Yr) <br /> <br />28d, PRONOUNCED DEAD IHo"rl <br /> <br />M <br /> <br />M <br /> <br />289.' On tne basl$ of exa.mination a.M' Of inIJe$tl9a1ion. In my opinion dealn OCCufted at <br />lhe lime, date and place and due to lhe causers) stated. <br /> <br />3O.b WAS CONSENT GRANTED? <br />D YES 00 NO <br /> <br />31 <br /> <br />Neena Biswas MD <br />320. REGISTRAR <br /> <br />Iowa HCS N Broadwell, Grand Island, NE. 68801 <br />32b. DATE FILED BV REGISTRAR (Mo.. Oay. Yr./ <br />JAN 1 6 2003 <br />