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<br /> Lot 12 and Lot 14 in Block 25, in College Addition to West Lawn, an Addition
<br /> to the City of Grand Island, Hall County, Nebraska. -c:s-'
<br /> ""
<br /> c
<br />
<br />
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STA TE DEPAlliME/JlT OF HEAL TH,
<br />n CERTIFIES THE BELOW TO BE A TRUE COpy OF AN ORIGINAL RECORUc-'ijf!/~-~"!!E StA TE
<br />DEPARTMENT OF HEALTH, BUREAU OF VnAL STATISTICS, WHICH I~~l. ",.Eiji~Y FOR
<br />
<br />
<br />~~TI7~ 200809218 ~m
<br />
<br />LINCOLN, NEBRASKA NEB/fi{$'KA tiBPARf/M.-r:f!!;!#AL TH
<br />---=.:, ,7~,:"~ " .: ._,....~--=:7-:-- _~.::-~, ': :7~.:=-
<br />STATE OF NEBRASKA - DEPARTMEN~:~_~ff.j~:'-'-o:~-=- .
<br />BUREAU OF VITAL STATISTICS-=~o-,.J-'.~""
<br />CERTIFICA TE OF DEA TH-"":~- _oc-',,""'""--
<br />
<br />Grand Island Nebraska
<br />1 SOCIAL SECuRTIY NUMBER
<br />
<br />
<br />uNDE.R 1 YEAR
<br />5b MOS DAYS
<br />
<br />
<br />6 DA TE ~F 61F1TH IM0t7tf1. Day Y~arJ
<br />
<br />1 DECEDENT - NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />2 SEX
<br />
<br />J DA.TE OF DEATH !Man'" Oa~ YfNlrl
<br />
<br />Ervin
<br />
<br />Frank
<br />
<br />Dahlke
<br />
<br />Male
<br />
<br />September 8. 1995
<br />
<br />4 CITY AND STATE OF 61FlTH (If not " U.SA" nameCOUrl'iy)
<br />
<br />6b FACILITY - Name
<br />
<br />(If no! ,nstmJOOn, gille 5freer ano n/Jmb8rJ
<br />
<br />HOSPITAL 0 Il1patiBm
<br />o fR OlIrpatJenl
<br />o DOA
<br />
<br /> 27. 1914
<br />DTMEA 0 ~'~h,Jr5u19 Home
<br /> [] ~~lclMte
<br /> 0 OI:ner 15{;;IeClfl,i,
<br />
<br />508-10-9773
<br />
<br />2111 N. Huston
<br />
<br />He
<br />14. USUAL OCCUPATION IG'.. krno/ _. dono <IvMg mosl
<br />o/"""''''9'.1e...-d_,
<br />Painting Contractor
<br />
<br />'6. FATMER - NA"'E FIRST MIDDLE
<br />
<br />American
<br />140 KIND 01' BUSI~ESS INDuSTRY
<br />
<br />
<br />(fnCIIJ(Jr"'!}Ztp Cot1eJ ge IN SlOE CITY LIMITS
<br />
<br />6< CITY TOWN OR LOCATION OF DEATM
<br />
<br />8<l IN SlOE CITY LIMITS
<br />
<br />Grand Island
<br />9a RESIDENCE" STATE 191>.. GOUNTY
<br />
<br />Nebraska Hall
<br />11. ANCESTFlY Ie g Itahan. M@);lcal"\. German, etc.1
<br />
<br />68803' y..iR] No 0
<br />
<br />
<br />IS"",,'1y1
<br />
<br />13 NA~E OF SPOUSE IIf Wlr~ give maJdBn nameJ
<br />
<br />Painting & Decorating
<br />LAST " MDTMER
<br />
<br />Esther Theewen
<br />'5 EDUCATION ISO'''A, onl, noghosl g'''''. "'''_I
<br />EliII'mt'n1arv CM" ~ry rO-12) College j 1 .4 Qf tt. I
<br />12
<br />
<br />John
<br />
<br />H.
<br />
<br />
<br />FIFlST
<br />
<br />MIDDLE
<br />
<br />MAIOEN SURNAME
<br />Liedke
<br />
<br />Minna
<br />
<br />NMN
<br />
<br />'8. WAS DECEASED EVER IN US ARMED FORCES?
<br />(Yes.. no or 1.111":.) (Il yes. give war and ciale!:. of tit:nVIC8$1
<br />NO
<br />
<br />Esther Dahlke
<br />
<br />1 gb INFORMANt
<br />
<br />MAILING ADDRESS
<br />
<br />[STREET OR R.F.D NO.. CITY OR TOWN. ST ATE. ZIPI
<br />
<br />2111 N. Huston.
<br />20 EMBALMER - SIGNA tURE . LICENSE NO
<br />
<br />Grand Island. Nebraska 68803
<br />2,. METHODOFDISPOSITIO. 2'b DATE
<br />
<br />I 211:: CEME'TERY OFl CFlEMp,TOR'l' NAME"
<br />
<br />Not Embalmed
<br />
<br />o Bu"OI ORemo'a1 Sept. 8.1995
<br />
<br />Central NE.Cremation Service
<br />
<br />22.. FUNERAL MOME - NAME
<br />
<br />21d CEMETERy OR CREMATORY LOCAtiON
<br />
<br />CIT' OR TOWN
<br />
<br />STAn
<br />
<br />Livingston-Sondermann F.H. g]crem"""" 0000",""
<br />22b FUNERAL fiOME ADORESS ISTREET DR R.F.D. NO. CITY DR TOWN. STATE. ZIP)
<br />
<br />Gibbon.
<br />
<br />Nebraska
<br />
<br />505 West Koenig. Grand Island. Nebraska 68801
<br />
<br />Ibl
<br />DUE TO. OR AS A"CONSEOUENCE CF
<br />
<br />
<br />YO~ECAUSE PER L:D~ ~ND~~
<br />
<br />1"900=~~~
<br />
<br />Inl8l"\/"al between onset and dP.illh
<br />
<br />23 IMMEDIATEC~SE
<br />PART ,
<br />I
<br />lal .
<br />DUE TO. OR AS A CONSEOUENCE OF
<br />
<br />Inl8t'val bel'Wfe8n 0fI'!ie1 and de'al"
<br />
<br />
<br />o AC:Cactent 0 Unde1ermlned
<br />o Su",'" 0 P.""!1g
<br />D Homicide Invesllga11()fl
<br />
<br />268. INJURy A"t WORK
<br />Yes 0 No 0
<br />
<br />2&j. LOCATION
<br />
<br />STREET OR RFO NO
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />27a DATE OF DEATH (Mo. Day. Yr.)
<br />
<br />28a. DATI; SIGNED IMo DBy Yr J
<br />
<br />2Gb TIME OF" DEATH
<br />
<br />$" of. 8 September 1995 $~ i
<br />I ~ 270. DATE SIGN~D lMo O'Y Y,! 27c Tlt,lE OF DEATH 1!! ,.. e 26< PRONOUNCED DEAD lMe O.y, y,:
<br />!i~ l~~~
<br />~J~ ~p TO~~:~=~.~::::":"~"a1..no~?e.:.:?ue'o~ a M ~ U ~ 28e On~_s~...m'na'~,no ~___,'nmyop~n""noccu'~.'
<br />
<br />"f- C8uMlsl slaII!I(I. W ~ J /1 ~ u ~ me lime. daM and. place af"(J due 10" ca..JS@1S) staled.
<br />
<br />IS. nalUfeand'titM =...J ~ I ,ilUr8anc1TIIe
<br />29 DID TOBACCO USE CONTRIBUtE TO tM, DEA tM? 30.. MAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />XtrVES 0 NO 0 U"NOWN 0 YES "eg NO
<br />
<br />31. NAME AND ADDRESS OF CERTIFIER IPMYSlCIAN: CORONERS PMVSICIAN DR COUNTY ATIORNEYI (TYPO ~ Pnntl
<br />
<br />M
<br />
<br />28d. PRONOUNCED DEAD (Hou"
<br />
<br />M
<br />
<br />
<br />o
<br />
<br />YES
<br />
<br />o NO
<br />
<br />Dr. W. J. Landis.
<br />
<br />2444 W. Faidley. Grand Island. Nebraska 68803
<br />
<br />. REGIS1'RAA
<br />
<br />
<br />]2b DATE FILED BY' REGISTRAFI (Mo,. Da.". Yr.1
<br />
<br />SEP 111995
<br />
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