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<br /> , , J')> '......... '.':,' ,~-
<br /> 1. DECEDENT'S-NAME (First. Middle, Last, Sufflxl 2. SEX I , . ,'Ill '3.'P~TE 'Of,pEATH (Mo.. Day, Yr.)
<br /> Harold Arthur Luebbe Male' \ \. "'~' . . ". Jy,nEf15, 2008
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE. Last Birthday b. UNDER 1 YEAR k UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. 1 DAYS HOURS 1 MINS.
<br /> Grand Island, Nebraska 91 November 1,1916
<br /> 7. SOCIAL SECURITY NUMBER ea. PLACE OF DEATH
<br /> 720-03-8317 HOSPITAL IXIlnpatlent OTHER 0 Nursing HomelL TC o Hospice Facility
<br /> 6b. FACILlTY.NAME (If not Institution, give street and number) o ERlOutpatlenl o Decedenrs Home
<br />a:::
<br />0 Good Samaritan Health Systems O'OOA o Other (Specify)
<br />I-
<br />CJ
<br />W Sc. CITY OR TOWN OF DEATH (Include Zip Code) ISd. COUNTY OF DEATH
<br />n::
<br />is Kearney 68848 Buffalo
<br />...J Sa. RESIDENCE-STATE 19b. COUNTY 19c. CITY OR TOWN
<br />~
<br />w Nebraska Hall Grand Island
<br /><i: 199. INSIDE CITY LIMITS
<br />:::l 9d. STREET AND NUMBER 1ge. APT. NO. 191. ZIP CODE
<br />u.. 3990 W. Capital Ave. 122 68803 ~YES 0 NO
<br />>.
<br />..c lOa. MARITAL STATUS AT TIME OF DEATH l&I Married 0 Never Married I lOb, NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />II
<br />!i: o Married, but separated 0 Widowed 0 Divorced 0 Unknown Irene Vieth
<br />j 11. FATHER'S.NAME (First, Middle, Last, Suffix) 112. MOTHER'S-NAME (First, Middle, Malden Surname)
<br />~ August Luebbe Lillie Moeller
<br />is. 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. 1141. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />e
<br />8 (Yes, No, or Unk.) No Irene Luebbe Wife
<br />.! is. METHOD OF DISPOSITION 16a. EMBAlMER-SIGNATURE 116b. LICENSE NO. lSc. DATE (Mo., Day, Yr.)
<br />~ l&I Burial o Donation Laurie D. Sheffield 1397 June 19, 2008
<br /> o Cremation 0 Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br /> o Removal o Other (Specify) Grand Island City Cemetery Grand Island Nebraska
<br /> 17s. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 117b. Zip Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> CAU::it; VI" DEATH (See instructions and examPleS)
<br /> 11. PART I. Enter thlll chain Df IIYBnbl. .dIHa.4UI, InJunGl. 01' compUcatlonl.f;hat directly caused the death. DO NOT enter t.rmlnillllllV8nm 8uch .II. Cardiac arrGlt. APPROXIMATE
<br /> INTERVAL
<br /> respiratory Iorrelrl:, Dr v.ntrlcullillr flbrlllatlon without Ihowlng the etiology. DO NOT ABBREVLATE. Enter only onllll ca..... on .. line. AcId .ddltlon.lllne.lf nece...ry.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final al Cardlo-pulmonary Arrest Minutes
<br /> dl.... or condition re.ultlng
<br /> In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Sequentially lIet condition.. II b) Brain Trauma 4 Days
<br /> any. leading to the cau.. lIoted
<br /> on IIn. .. DUE TO. OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERL YINO CAUSE C) Large Acute Right Subdural Hematoma 5 Days
<br /> (disease Dr Injury that Inltlalad
<br /> the events resulting In delllth) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> LAST d)
<br /> is. PART II. OTHER SIGNIFICANT CONDITIONS.condltlons contributing to the death but not resulting In the underlying caulS given In PART I. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br />n:: DYES l&I NO
<br />w 20. IF FEMALE: 21a. MANNER OF DEATH 21b.IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />ii:
<br />i= o Not p",unont wllhln poet year 1&1 Natural o Homicide o Driver/Operator DYES l&I NO
<br />n:: o Pregnant at time of death o po_nger
<br />W o Accident o Pending In_gatlon
<br />CJ
<br />~ o Not pregnant. but pregnant within 42 dayt of death o Suicide o Could not be dotennlned o Pedeetrian 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />o Not pregnant. but pregnant 43 dllY' to 1 year before death o Other (Specify) TO COMPLETE CAUSE OF DEATH?
<br />" DYES o NO
<br />.!l o Unknown If pregnant within the past year
<br />'"
<br />is. 22a. DATE OF INJURY (Mo., Day, Yr.) 122b. TIME OF INJURY I 22c. PLACE OF INJURY.At home, farm, street. factory, office building, construction site, etc. (Specify)
<br />E
<br />8 Not Applicable
<br />'" 22d. INJURY AT WORK? r2e. DESCRIBE HOW INJURY OCCURRED
<br />..c
<br />0
<br />I- DYES ONO
<br /> 22f. LOCATION OF INJURY. STREET & NUMBER, APT.NO. CITYfTOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo.. Day, Yr.) 24b. TIME OF DEATH
<br /> .:~ June 15, 2008 .:~j
<br /> ... u I 23c. TIME OF DEATH )~ > 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> j~>- 23b. DATE SIGNED (Mo., Day, Yr.)
<br /> to.;;! Julv 7,2008 11:48 AM to. 0(...J
<br /> 8 g> 0 ~3d. To th. beat of my knowledge. death occurred at tnllll time, date and place S15~ 248. On the ~BI. or eKamlnatlon and/or InvlIIIstlgatlon, In my opinion deilth OCCurred at
<br /> ! :g and due to the GilUH(.) ttated. (Slgnarul'IIII and Title) J il the time, date and place and due to th& CauN(S) stated. (Signature and Title)
<br /> ~ ~ Chinyere N. Obasl, MD ~ u
<br /> u!
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 12sa. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? I 2Sb. WAS CONSENT GRANTED?
<br /> DYES l&I NO o PROBABLY 0 UNKNOWN DYES l&I NO Not Applicable If 26a Is NO 0 YES o NO
<br /> 27. NAME, TITLE (PHY5ICIAN, ...., ype or Print)
<br /> Chinyere N. Obasl, MD, 123 W 31st Street, Kearney, Nebraska, 68847
<br /> 2ea. REGISTRAR'S SIGNATURE~ ....., A. ..,...-,- I 28b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.) I
<br /> (1 ....< .., July 10, 2008
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND t(tJ~,SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL REt!.QlW 0 ):}L'f WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlStlCfrSeCtt i f/JIf'/tH,/S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. "':,r... ....;.~..,..~.,...,..Ij. 'I
<br />\ ' ., I
<br />DATE OF ISSUANCE " ~ . _ ~.'~, I
<br />
<br />~~;;~~:8RASKA 2008099 31 ~~ ~iJii.)
<br />
<br />'1 '~}. &.!f ,,!..- '~\,~,:":)" :,,>~~: 1".1'1 iI',i
<br />STATE OF NEBRASKA. DEPARTMENT OF HEALTH AND HUMAN S",~~~V$:~ ^ ~'f.~". .=~ _:~ 0800935
<br />CERTIFICATE OF DEATH ",', '. ~nr\- .' .\ ".~
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