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<br />
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL TJ;;t,1Jf/tfJ~"';f3ERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA5k'A~Wfj!Jt VfHEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR:VI~"8.51Z0RDS~~' <~ ~
<br />"N.':,br:r~ i.r'~~~1,
<br />DATE OF ISSUANCE . ~"_i;J':'~I,
<br />'$71WLE:t, ~. GOPER' '. ( , ",
<br />A,$SI$TA . AAro,R'iGjS~AR ~j
<br />OE1!ART. '. hl'EAttH ,MID '~
<br />LINCOLN, NEBRASKA 1tI1.11SiJ4.N S~RVICE$' ,: :;; .~, .
<br />I C' '. ''/c- '. ..r'i~" c) .,-
<br />, 1t ". ," ~ ,.. c; \... ..' W ..liI~-.'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMANSE~YI.c~'t'.,. ~":"". ,.~'k'-e1'3' .
<br />C IC E OF DE ' )., '0, VQ.'Cl
<br />1. DECEDENrS-NAME (Flrs~ Middle, Last, sum.) 2. SEX- \ ~.3\~. .'~F< ..Dey,Yr,)
<br />Eunice Ann stol tenberg B~cker Female Octobe;'15,2008
<br />
<br />OCT 2 7 2008
<br />
<br />200901769
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />as. AGE-Laat Birthday Sb: UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo.. Day, Yr.)
<br />
<br />(Y...)
<br />
<br />HOURS MINS.
<br />
<br />MOS. DAYS
<br />
<br />Dannebrog, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />September 20,1927
<br />
<br />81
<br />
<br />8s. PLACE OF DEATH
<br />~ 0 InpaUent
<br />o ERlOutpatlent
<br />DDOA
<br />
<br />8b. FACILITY-NAME (If not Inatltutlon, give a~et and number)
<br />
<br />2IIWii IX! Nu,,'ng HomelL TC
<br />o Decedent.s Home
<br />o other(Speclly)
<br />
<br />o Hospice Facility
<br />
<br />507-30-9325
<br />
<br />~
<br />1:
<br />!E
<br />Ql
<br />~
<br />!
<br />ii
<br />~
<br />U
<br />Ql
<br />lD
<br />~
<br />
<br />Wedgewood Care Center
<br />Sc. CITY OR TOWN OF DEATH (Include ZIp Code)
<br />Grand Island 68803
<br />aa. RESIDENCE.sTATE
<br />Nebraskl:l
<br />ed. STREET AND NUMBER
<br />4656 N. 90th Road
<br />
<br />ig. INSIDE CITY LIMITS
<br />o Yes iii No
<br />
<br />ed. COUNTY OF DEATH
<br />
<br />9b. COUNTY
<br />
<br />
<br />Hall
<br />
<br />af. ZIP CODE
<br />68824
<br />
<br />10a. MARITAL STATUS AT TIME OF DEATH 00 Mamed 0 Never Married lOb. NAME OF SPOUSE (FI..t, Middle, Last, sumo) Ifwtfe, give melden name.
<br />o Married, but aeparated 0 Wldowad 0 Divorced 0 Unknown
<br />
<br />
<br />11. FATHER'S.NAME (FI..t, Middle, Lost, Sumo)
<br />
<br />12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br />
<br />Hattie
<br />
<br />Kroe er
<br />
<br />Au ust
<br />
<br />Schultz
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dates olse..lce IIYes.
<br />
<br />14b. RELAnONSHIP TO DECEDENT
<br />
<br />(Yes, NOt or Unk.) No
<br />
<br />Son
<br />
<br />15. METHOD OF DISPOSITION
<br />[jJ Bl,JrI.1 0 Dc;matlon
<br />o C...rnathm 0 Ent(nnbmtnt
<br />o Removal Dother(sp8e;lfy)
<br />
<br />15b. LICENSE NO.
<br />1..3 9 7
<br />
<br />1Bc. DATE (Mo., Day, Yr.)
<br />October 20, 2008
<br />STATE
<br />
<br />CITYITOWN
<br />
<br />Grand Island City Cemetery
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (S~et, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />
<br />CAUSE OF DEATH See Instructions and exam les)
<br />
<br />11. PART I. Ent... the t.haln of avonts ~ dlll.aauj InJuries. 0" l::omplh:atlona- thllit dl..-dly UI.IMd tM chIlth. DO NOT .nae,. ~nnllUi.l .v.nta :IIue;h a. e;atdlac amat,
<br />r..plndory a"""t. qr ventricular fibrillation without 'howlng t.... etiology. DO NOT ABBRINIATE.. Enttll' only OM ca..... on a line. Add addltlonaJ line. If nee.'lIty.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />APPROXIMATE INTERVAL
<br />I
<br />onset to de.th
<br />I
<br />
<br />I '1eet.-Y
<br />
<br />IMMEDIATE CAUSE (Final r1 \
<br />
<br />dlseese or condition resulting a) \.:::)', 0 b \ ",-. c +eYn C\
<br />In death) ~ ~
<br />
<br />lY\\J \ T\
<br />
<br />rne.-
<br />
<br />DIlE Tn, OR AS A CONSE~UENCE OF:
<br />
<br />onset to death
<br />I
<br />I
<br />
<br />Sequentially lI.t candltlomr., If b)
<br />sny, leading to the CaUse listed
<br />on line a.
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />an..t ta death
<br />I
<br />I
<br />
<br />Enter the UNDERLYING CAUSE c)
<br />(dltutase or Injury that Initiated
<br />the events resulting in death)
<br />LAST
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on.et to death
<br />I
<br />
<br />I
<br />
<br />d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDmONS-Condltlone contributing to tho death but not reeultlng In the underiylng cauae given In PART I.
<br />
<br />1a. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />DYES I.iJNO
<br />
<br />a::
<br />w
<br />it:
<br />1=
<br />~-
<br />u
<br />~
<br />'C
<br />1;
<br />ii
<br />~
<br />U
<br />Gl
<br />10
<br />o
<br />I-
<br />
<br />20. IF FEMALE:
<br />)it Not pregnant within put year
<br />"-"11_"'_--' -"
<br />o Not pregnant, but pregnant within 42 day. gf death
<br />o Not pregnant, but pregnant 43 day. to 1 year before death
<br />o Unknown If pregnsnt within the past yesr
<br />
<br />21 e. MANNER OF DEATH
<br />,ij Natural 0 Homicide
<br />-0 -"B~'1MllI\l'GlIII"n
<br />o Suicide 0 Could not b. d.tennlnBd
<br />
<br />21b.IF TRANSPORTAnON INJURY
<br />o DriverlOperator
<br />. f] P...anger
<br />o Ped..trlan
<br />o Other (Specify)
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />DYES ~O_._
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />DYES oNO
<br />
<br />22a. DATE OF INJURY (Mo., Dsy, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY-At homo, farm, street, foctory, office building, conotructlon alte, etc. (Speclly)
<br />
<br />22d.INJURY AT WORK7 22e. DESCRIBE HOW INJURY OCCURRED
<br />DYES oNQ
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYITQWN
<br />
<br />ZIP CODE
<br />
<br />STATE
<br />
<br />z
<br />~:$
<br />...!.!
<br />Qllll
<br />i!l:>-
<br />D.0....J
<br />g g>~
<br />".-
<br />1:-g
<br />~~
<br />
<br />23s. DATE OF DEATH (Mo., Dey, Yr.)
<br />October 15, 2008
<br />
<br />m
<br />
<br />241. DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />,.,~~
<br />..,uz
<br />... iill!J
<br />;i!l:I=>-
<br />D.o..< ..J
<br />g~~i5
<br />" Wz
<br />1:Z::>
<br />000
<br />I- fl:u
<br />0,-
<br />UO
<br />
<br />
<br />23c. TIME OF DEATH
<br />
<br />240. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />
<br />jO
<br />
<br />11:25
<br />
<br />A.m
<br />
<br />m
<br />
<br />23d. To the beet of my knowledge, desth occurred at the time, date and place
<br />and due to the cauee(o) st.ted. (Slgnalure and Title)
<br />
<br />248. On the basi. of examination and/or Inv.,tlg_t1on, In my opinion de.th occurred
<br />at the time. date and place and due to the cauee(e) steted. (Slgnatura and TIUe)
<br />
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />o YES NO 0 PROBABLY 0 UNKNOWN
<br />
<br />25a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />o YES NO
<br />
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a Is NO 0 YES 0 NO
<br />
<br />2? NAME, TITLE AND ADDRESS OF CERTIFIER (PHYllICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Jennifer Brown, M.D., 729 N. Custer Ave, Grand Island, NE
<br />
<br />68803
<br />
<br />28s. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />
<br />OCT 2 2 2008
<br />
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