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<br />STATE OF NEBRASKA
<br />
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL TH AND HUM/:lN,5..Ef.YICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE N~BRASKA DEP~EN~ OF'fIEx.IL, TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL R.ELQRPS:' ".(: ,.' . \i .
<br />
<br />DATE OF ISSUANCE N 1- ~;::.,if s.~ '~, ' 't,
<br />/.JJN'~ .
<br />STANLEY"So' t60PER ... -. .
<br />ASSISTAivr.::srATI{Rqel$AR~. . ......
<br />DEPART~Ew:r:OF k/l/JIL'fll4NtJ
<br />HUMAN SE~JllC;:ES " .~
<br />/ (.)... /~~ '_0"',.''':'' ",' : l'))~ ..
<br />;' "."..' (r'" '" Y-,.' ('J .'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SU~Il'O~.r\ "8" '.:' '3i !2' '2"~8'~1" 1\ .,:
<br />CERTIFICATE OF DEATH j ~' (' , " . :J..-.~
<br />.- ;~ SEX 3. DATE'OF DEATH (Mo.,. Day,.Yr:i'.
<br />Male December 6, 2008
<br />
<br />FEB 2 0 2009
<br />
<br />..
<br />
<br />200901493
<br />
<br />;''',
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />DECEDENT'S-NAME
<br />
<br />(First,
<br />Gordon
<br />
<br />Middle,
<br />Charles
<br />
<br />Last,
<br />Haack
<br />
<br />Sulflx)
<br />
<br />Grand Island, Nebraska
<br />
<br />85
<br />
<br />
<br />5e. UNDER I DAY 6, DATE OF BIRTH (Mo" D.y, Yr.)
<br />MINS,
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FORolGN COUNTRY OF BIRTH
<br />
<br />58. AGE-la.st Birthday
<br />(Yrs.)
<br />
<br />December 12, 1922
<br />
<br />7. SOCIAL SoCURITY NUMBER
<br />505-20-5230
<br />
<br />8a, PLACE OF DEATH
<br />1:iQSfJIAI., :&!Inp.tlent
<br />
<br />QIlJal; D Nursing Homa/LTC Q Hospice F.Clllty
<br />
<br />FACllITY.NAME (If not Institution, give street and number)
<br />
<br />D ER/Outp.lIent
<br />
<br />o D.c.d.nt's Horn.
<br />
<br />St. Francis Medical Center
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island
<br />
<br />68803
<br />
<br />f' COUNTY
<br />Hall
<br />
<br />Q lXl'I D Other (Specify)
<br />
<br />6d. COUNTY OF DEATH
<br />Hall
<br />
<br />9.. RESIDENCE-STATE
<br />
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />
<br />1109 West Ko.':.~~~,_.
<br />lOa. MARITAL STATUS AT TIME OF DEATH ~ M.rrlad D Navar Marrl.d
<br />
<br />
<br />91. ZIP COOE
<br />68801
<br />
<br />9g. INSIDE CITY LIMITS
<br />XI YES D NO
<br />
<br />1 Ob. NAME OF SPOUSE (Firsl, MiddlO, Last, Sulf;x) It wlto, give maidon name.
<br />
<br />D Marriad, but saparatad 0 Widowed D Divorced D Unknown
<br />
<br />Donna Scheel
<br />
<br />11. FATHER'S-NAME (First,
<br />
<br />Ernest
<br />
<br />Middle,
<br />
<br />Last,
<br />Haack
<br />
<br />Suffix)
<br />
<br />12. MOTHER'S.NAME (First,
<br />Mabel
<br />
<br />Middle,
<br />
<br />M.id.n Surn.me)
<br />Hann
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give d.te. ol.ervie. if ya., 14a,INFORMANT.NAME
<br />1"~~,;'run~/3/1943 3/25/1946 Donna Haack
<br />
<br />D Don.tlon
<br />
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />~Burial
<br />
<br />
<br />o
<br />
<br />16c. DATE (Mo" Dey, Yr. )
<br />December 10, 2008
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />o Cremation 0 Entombment
<br />
<br />CITY /TOWN
<br />
<br />STATE
<br />
<br />D Otnar (Sp.eify)
<br />
<br />Grand Island Cemetery,
<br />
<br />Grand Island, NE
<br />
<br />IMMEDIATE CAUSE:. /1
<br />
<br />IMMEDIATE CAUSE (Fln.t la) A/Ju.J!.i- ~;1/t ~...
<br />d_orcondnlon,""uIUng DUE TO, ~R r A CONSEQuENcE OF: -. ~ ..-.'/
<br />
<br />:.::I.llyn.ICOndIIIOnS,If (b) 7V~~ 7-~
<br />
<br />.nY,I..dlngtotho..uoell.led DUETO,ORASACONSEQUENCEOF: - ..-
<br />online..
<br />En....lhe UNDERLYING CAUSE
<br />(dl..... or Injury th.llnltialed Ie)
<br />th. .v.nls fBSultlng In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />lAST
<br />
<br />-~~
<br />
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS IStr..t, City or Town, Slate)
<br />Apfel Funeral Horne, 1123 West Second,
<br />
<br />Grand Island, NE.
<br />
<br />
<br />PART I. Enter the chain of evenlsudlseaSGS, Injuries, or compllcatloMnthat directly caused the death, DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular Ilbrlllatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on alinB. Add addilionallines if necessary,
<br />
<br />d.- :3 ~
<br />
<br />onset to de.lh
<br />
<br />onset to death
<br />
<br />Id)
<br />
<br />18 ~ER SIGNIFICANT CONDITIONS-Conditions contllbutmg to the death but not re.ulllng In the underlYing Caus. given In PART I
<br />
<br />J:J~
<br />
<br />20. IF FEMALE:
<br />
<br />D Aecid.ntD P.nding Invesllgallon
<br />D Sulcid. D Could not be determin.d
<br />
<br />21 b.IF TRANSPORTATION INJURY
<br />D Driver/Oper.tor
<br />
<br />o P....ng.r
<br />
<br />o Pedestrian
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER_c~nACTED?
<br />
<br />DYES Ci" NO
<br />
<br />21 c. WAS AN AUTOPSY PERFORMED?
<br />
<br />21a. A ER OF DEATH
<br />alural [J Homicide
<br />
<br />D NOI pregnanl wilhin pest ye.r
<br />D pragn.nt.1 time of d.alh
<br />o Not pregnant, but pregnant within 42 days 01 death
<br />CI Not pregnant, but pregnant 43 days to 1 year before death
<br />! 0 Unkno~~.",i,f.~~~nant ~~~hin the past year
<br />,( 22e. DATE OF INJURY (Mo., O.y, Yr.)
<br />
<br />DYES
<br />
<br />~
<br />
<br />D Other (Specify)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />COt,tPLETE CAUSE OF ~ATH?
<br />D YES ~O
<br />
<br />DYES D NO
<br />
<br />
<br />m
<br />
<br />22b. TIME OF INJURY
<br />
<br />22c. PLACE OF INJURY.At homa, tarm, street, taClory, office building, construction .lte, etc. ISpecify)
<br />
<br />22d.INJURY AT WORK?
<br />
<br />22t. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />23.. DATE OF DEATH IMo" D.y, Yr 1
<br />DeceMber 6 I 2008
<br />
<br />24e. DATE SIGNED (t,to" D.y, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />23c. TIME: OF DEATH
<br />6:45 am
<br />
<br />...~ 1U
<br />..,r;:>:
<br />~u;!!i
<br />~H~
<br />g~~~
<br />.!l~5
<br />.28~
<br />
<br />m
<br />
<br />24e. PRONOUNCED DEAD (t,to., O.y, Yr.) 24<1. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis 01 examination and/or invBstigation, in my opinion death occurred at
<br />tnalime, date and place and due to the caus.(.) stated. (Signature and Title) ...
<br />
<br />26e. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES 0 D PROaABLY D UNKNOWN DYES II NO
<br />27. NAME~i'ii'LE ANDADDRESSO"-C:"ER-iiFiEFi"-(PHYSICIAN, CORONoR'S PHYSICIAN OR COUNTY ATTORNEY) (TYp':'-"rPrint)
<br />John Wa. oner M.D. 800 N. Al he Ave., . Grand Isla.nd,
<br />
<br />26b. WAS CONSENT GRANTED?
<br />NOI Applic.ble if 26. ie NO D YES ~ NO
<br />
<br />28e. REGISTRAR'S SIGNATURE
<br />
<br />
<br />Nebraska
<br />
<br />68803
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo" Dey, Yr.)
<br />
<br />DEe 1 0 2008
<br />
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