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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANiJH~_~E$
<br />SYSTEM,IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RE~Wfir.~'W!TH
<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA T1ST_gti'11l>M'.W/11tfFtl$
<br />
<br />:::;::~:::::~TORY FOR VITAL RECORDS. /Vi1,~i'll~tlit\j\
<br />
<br />AUG 3 0 2001 200900951 .w~~~JfA~p~;-;
<br />ASS/~M1r SntTE REGlSTljURc;
<br />LINCOLN, NEBRASKA HEAL TH AND HtlIIAN.$E/ilVICES JlY6TEM.','
<br />STA TE OF NEBRASKA- DEPARTMENT OF HEAL rn AND HUMAN SER:YJCE5"FiJi>rc~~ItSUP~T
<br />VITAL STATISTICS -, OOd.. ,. -- .cc"
<br />CERTIFICATE OF DEATH- - .-.';-0 01
<br />
<br />09502
<br />
<br />I1DEcrOEN~. NAMt:
<br />I
<br />
<br />14 Clly AND STATE OF BIRTH
<br />
<br />'FiRSt"
<br />
<br />MI[\DL[ .
<br />
<br />! 2 SEX
<br />
<br />. .t~r~TE Of DEATH IMr:'J/1th Ollv, Yellrl
<br />
<br />LAST
<br />
<br />
<br />Ma r C h 2 2 , 1 9 3 2
<br />
<br />Helen
<br />
<br />Lucille
<br />
<br />Stahlnecker
<br />
<br />Female.
<br />
<br />UNOe:R 1 OA Y
<br />5c. HOuRS MINS
<br />
<br />August 20, 2001
<br />
<br />5 DAn:: OF BIRTH rMMth. Oa~v. Year)
<br />
<br />Iff flot ;~ USA fliime CO(jnr;~--'
<br />
<br />~a AGE. lasl Birthday
<br />
<br />UNDER' YEAR
<br />5b, MOS I DAYS
<br />,
<br />----.-l.
<br />8. PLACE OF DEA T H
<br />
<br />Winside,
<br />
<br />lYe" 6 9
<br />
<br />Nebraska
<br />
<br />7 SOCIAL SECURTly NUM13ER
<br />
<br />507-32-1774
<br />
<br />HOSPITAL
<br />
<br />lJ Inpallsm
<br />
<br />D ~R Outpatient
<br />D OOA
<br />
<br />OTHER
<br />
<br />D NurSing Home
<br />
<br />[X] Resldef\ce
<br />
<br />D Otner (S~Cdv'
<br />
<br />8b FACILITY - Name
<br />
<br />(If r?Dlrnstlrl,Jrion. give sffoel afl(j f1umoerJ
<br />
<br />Home:
<br />
<br />2311 N.
<br />
<br />Howard Ave.
<br />
<br />aI;:, CITY~T6WN OR LOCA TtON OF DEATH
<br />
<br />
<br />8d INSIDE CITY LIMITS
<br />
<br />~ ~rand I_=_lan~.
<br />. ..~ 'I'""'r- ~ ~ , I-.
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<br />A 68803
<br />Howard ve
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<br />Yes []g No D
<br />
<br />13, NAME. Or:' SPOUSE {ff w,fe. glvB maitJtM fla.me; Sr.
<br />Franklin "Stony" Stahlnecke1
<br />
<br />Nebraska
<br />
<br />11 ANCESlt=lY le,q l1ahan, Me~lcan. Germal"1, elLI
<br />(Spet.llyl
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<br />i 19(1 INFORMANT - NAME
<br />, Franklin "Stony" Stahlnecker Sr.
<br />..__..1
<br />ISTREET OR RFD. NO.. CIIY QR TOWN. STATE. llPI
<br />
<br />~---"~--,~~..
<br />USUAL OCCUPATION (GIVe kina 01 work QOne i;Jurmg most
<br />01 worj(lnt) lIIe. even if retireol
<br />Purchasing Agent
<br />
<br />~ATHe:II. NAME FIRST MIDDLE
<br />
<br />Grand Island City Hall
<br />
<br />15 EDUCATION ISpeclty only hIghest graoe complete-el)
<br />E1emenl8'l O2 SeI:;Otldarv (0. 12) COll69i r 1 .11 Or :I' I
<br />
<br />LAST
<br />
<br />17 MOTHEA
<br />
<br />MIDDLe
<br />
<br />MAIDEN SURNAME
<br />
<br />Iler
<br />
<br />Hansen
<br />
<br />Carrie
<br />
<br />Nielsen
<br />
<br />19b INFORMANT
<br />
<br />MAILING ADDRESS
<br />
<br />
<br />Grand Island, NE.
<br />e/ :; y 21. MEIHODDFDISPOSlliON
<br />
<br />0~ [X] Buflal 0 RemO.....;:!1
<br />
<br />68803
<br />
<br />21b, bATE
<br />
<br />21L: CEMETE"RY OR Cl=lE.MA TORY NAME
<br />
<br />August 23, 20 1
<br />2'" CEMETI,RY OR CREMATORY LOCATION
<br />
<br />Apfel-Butler-Geddes 0 Ccemal'OO D 00001'00
<br />22b, FUNERAl. HOME AOORESS Isn~EET OR R.t=.D, NO CITY OR TOWN, STATE. lJF'1
<br />
<br />Grand Islan.~LNE.
<br />
<br />Grand Island Cemetery
<br />CITY OR TOWN -_.~ STATE
<br />
<br />1123 West Second,
<br />23. IMM!;DIATE CAUSE
<br />PART
<br />I I., CA METASTATIC LUNG
<br />DUE TO. OR AS A CQNSEQue:NCE OF
<br />
<br />Grand Island, NE.
<br />
<br />68801
<br />
<br />
<br />rENTER ONLY ONE CAUSE PER LINE FOR lal Ibl. AND lell
<br />
<br />:6 MONTHS
<br />
<br />Inlerval between onset aM oealh
<br />
<br />Interval ~rwEten onset aM de;::j.th
<br />
<br />IDI
<br />DUF TO. OR AS A CONSEOUENCE Q~..
<br />
<br />Interval between onset ilncl death
<br />
<br />1'1
<br />PART OTHER SIGNIF=ICANT CONDITIONS Condi\lo~~ Contributing 10 the death Out nol related
<br />
<br />"
<br />
<br />I
<br />25 WAS CASE REFERRED TO MEDICA~
<br />EXAMINEII Oil CORONER'
<br />
<br />Yes [m
<br />
<br />
<br />26.
<br />
<br />26tJ OA TE OF INJURY {"Ao.. Day. Y".J 2Bc HOUR OF INJURY
<br />
<br />o Accident D Undetermined
<br />o SUlcld@ 0 ~8ridln~ 26e INJURY AT WOF=lK
<br />o HomiCide Iflvestlga/lo("J Yos 0 No D
<br />
<br />~~D^T[O~m:.ATH (Mn Day Yr)
<br />
<br />26g. LOCA nON
<br />
<br />SlREI;T OR A F D, NO
<br />
<br />~:lTY QR TOWN
<br />
<br />28a DATE StGN!:.D IMo,,08Y 'in
<br />
<br />.. "".-,,-. "l26b TIME OF DEATH
<br />
<br />--
<br />
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<br />....
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<br />
<br />
<br />[] NO
<br />
<br />AUG 20.2001
<br />Un, DATE SIGNED (Mo DiJY Yr i
<br />
<br />AUG 20. 2001
<br />
<br />P M
<br />
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<br />,~~ ~
<br />h.iOr
<br />!~~~
<br />1:i5i5
<br />~G~
<br />
<br />28e On tho Dasis 01 examination and' or investigation, In my opinion death Ol;cl,me<;l (II
<br />the time. date and place aM dUB 101M causer!;1 !jtaled
<br />
<br />28c. PRONOlJNC10 DEAD 11.10 08Y. Yo
<br />
<br />liME OF DEA TH
<br />
<br />~6" PIIQNQUNCED DEAD rHou"
<br />
<br />12: 20,
<br />
<br />'-'
<br />
<br />place (ln(l due to the
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<br />
<br />3O.b WAS CONSENT GRANlr:.D"
<br />DYES
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<br />
<br />Larry Hansen
<br />
<br />Grand Island, NE. 68803
<br />32b DATE FILED 6Y RWI~l1GI1 089 Y'/2 0 0 1
<br />
<br />M.D.
<br />
<br />3016 w.
<br />
<br />3:,J(I qEGISTAAA
<br />
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