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N T418 COPYCAI►1RWB PW 4418 #b SEAT OF THE 'N0"0IiG4 0 HEALTH AN@�111MML&AWES
<br />SYSTEM IT CER77RES THE BELOW TO BE A TRUE COPY, OF THE ORIGINAL— d: D 0K WffH
<br />THE NEBRASKA HEALTH ANOWUMAN SERVICES SYBTL�M, VITAL $TAi18;T1m�, W W*
<br />ECORDS. -- " z 1-N
<br />DAtet OF ISSUANCE
<br />OS/1`ORY FOR VITAL R
<br />JUN 1 -�.. µ
<br />UNCOLA�NLBRASKA: - - - -- T- HE.W.- A, & —A#AACI TER �...
<br />STATE OF Nd&t118KA DEPARTMENT OF IT k7tl r BUREAU, OF VITAL STATISTICS
<br />CERTIFICATE ©F; DEATH -
<br />1. DECEOEN - NAME FI ST MI DL T
<br />2: 5 X "°
<br />CA E F DEATH (MwnM, Day. Year/
<br />Georg.- NMN Gerber
<br />Male
<br />May 19, 1997
<br />4. CITY AND STATE Or BIRTH ttPo(N A USA.. name cminfryl' -.
<br />Sa:,'AGE, Last &rthday
<br />• UND R 4 YEAR
<br />UNDER 1 DAY
<br />16, : ATE OF BIRTH (MbnM. Day. Year/
<br />MP - Y
<br />l
<br />5c. HOURS MIN .,
<br />Belgrade
<br />(Yrs) �tb.
<br />76
<br />December 25, 1920
<br />. n—GIAL SECURTI .NUMBER '
<br />66, PLACE F DEATH
<br />+ ' 0 6 �' 5 O -979 �}
<br />HosprTAL' Inpatient "gTHPR: Nursing Horns
<br />woulatism Residence �-
<br />8b: Plot LITY :NaMe (/(riot m2ft0V% ploy!treat and 'ndmb 1
<br />+ 5t;.- Francis Medical Center
<br />El GOA ❑ Dew fS ec•Ifyl.
<br />CITY, TOWN OR LOCATION OF DEATH
<br />60. INSIDE LIMITS
<br />00, COUNTY 6, H N
<br />Grand Island
<br />tl
<br />Hall County
<br />Vd RESIDENCE 'r TATS
<br />"'.
<br />91). COUNTY
<br />..
<br />.Y.e
<br />N A .
<br />, ,. ;
<br />9e. INSIDE C LI MI
<br />Ni'kIi skc
<br />al
<br />ngi �1�i� .
<br />.%g iifO d,3
<br />�
<br />® No
<br />10. FACE - (0.0., Whft, 8163. Arnericait Indian,
<br />11. ANCESTRY 1&0., ore Min Mfxican, . 0"am etc) \ ,
<br />1$. MAAA1150 WIDOWED
<br />13. NAME OF SPOUSE tN wife. 0114.meid111,11 nai")
<br />ete.)(Sovelm
<br />.,White
<br />(Specov)
<br />German
<br />N@V @R -.' OIVORCID
<br />Katherina 'Schafer
<br />14s, USUAL'OCCUPATION (Give kind olNdrk done durMp mdst 14b:
<br />of working ft,, even if reared] °
<br />KIND OF`6U81NEffiS INDUBTRv "" " r ��
<br />13. "EDU ATION ' (Sped only h Neel' grade comply
<br />E me lery or See ery (0 -12) College (1 -d or 5.1
<br />Lr
<br />Baker
<br />Bakery
<br />tR Grace
<br />1 @. PATH FIRST MIDDLE LAST
<br />1 rI D ' ,, •
<br />MO HE FIRST MIDDLE MAIDEN SURNAM
<br />.
<br />Ph lip NMI, Gerber,.
<br />Katherina NMI Gerber
<br />' `.. 1). A E 3 .EVER IN U.S. '. ARM FORCES? "'- "'^ ` ""
<br />1 ®a. IN ORMANT = NAMH
<br />(Vey nP,, 07 dnk 1 ' II Yee give war and dales of services)
<br />-
<br />N/A I,
<br />Otto G:e ben
<br />1NF RMAF�TsI • MAILING ADDRESS " [STREET OR R. D: NO, CITY OR TOWN, 37AT I 1
<br />l
<br />1' street /, St,. Pauli Ngbraska 588'73 v
<br />a ,..
<br />AL SIGN AIL A LICENSE
<br />21a METHOD OF'DISPOSI ION '.,21b,
<br />DATE Z1
<br />G: CEMETERY OR CREMATORY NAME
<br />,.
<br />4
<br />/
<br />1 ,
<br />�ednal []Renmal
<br />rya 23,"n�1997'
<br />Y
<br />Westllawn memorial Park Can
<br />'4 2sk•FU E AM - - - -_ "' LL,„.
<br />-' ..,` ___ .- "'
<br />21d. CBMET RYORCREMATORY',L ATION - C17VORTOWN STATE
<br />' `sane Funeral Home M
<br />ElCrerYieM7i1 �Daiejian
<br />'' Grand Island, Nebraska
<br />F .
<br />FUNERAL ig ADDRESS ISTREET OR 'R.F...N,,,C R'. TE.' IPI ....: ..._..:. __ ,��,_.._,'�.. ....�.•� — .4.._...:.._'
<br />j'
<br />North, Fro t._ 9t r Gkan'd Island,,. iabk
<br />.�21� W. N.4r �' asl�a 8803 _
<br />�1 f�1
<br />_ _
<br />- �� " Tit . sell onset and aiff '
<br />IMMEp T CAUffiEi '�° (ENTER' 0 LY�ONE CAUSE PER;L NB FOR la) Ybl AN loll
<br />PART'
<br />1
<br />al
<br />E 0. R A-CO EOtY@ . _. .....� ._. ...:- A ..- ,- .T.. ._ _., 1 I Inlervel belwean ones end aealn ..
<br />, , ,....
<br />DUE TO; ONE I Interval between onset and death
<br />PR'AS A OUENCE
<br />e
<br />,.
<br />col I
<br />OTHER SIGNIFICANT CON ION Woes contdbuUng the e—tut not relaled
<br />PARTAI
<br />R 111 A TH A
<br />PREGNANCY IN THE PAST 3 MONTHS? ',
<br />AUTOPSY
<br />WAS' ASE REF99RCS 'T MEDICAL
<br />EXAMINER OR CORONER?
<br />.. .._..,, ;.. ., ,.
<br />(Ages 10.541 Vey Ntl
<br />Yea No
<br />Ves No
<br />"28"ATF:pFINJURY
<br />,..
<br />oAccidant ❑ Undetermined
<br />%M6;,t7ey:.Yr.7"
<br />I.. 1 1
<br />-286; ROU OF•INdDRP..'.` 2Stl:0ESOR18L�HONTINJURY 'OCCURRED.- ."'" -.,.' .... . .
<br />.. .M. i
<br />I'PpfdMg
<br />2Qg •INJURY AT VyQRK';.
<br />:28f CEOtlI 1�NllCY( -ftJb1771 Tgfm.9Gaet factory
<br />e
<br />2Ag, LOCATIO E
<br />Inveeagation.
<br />J-I Ye No
<br />bull
<br />(MIX ay r./ .. -. •.-' ,. —•..
<br />6
<br />..,�. ".
<br />28a DATE SmED - 'ANd:. ppyYr,/ "__ _"
<br />? I
<br />'2867-TIME OF DEATH
<br />OEI
<br />lT
<br />. "fIM or D " ,,;
<br />�Re PRO OUNCEp DEAD /Mb AA , Yr,
<br />260 PAO NOUNCEp DEAD. (Hdurl
<br />+
<br />.M
<br />�e �e�elue
<br />°
<br />the Beal ot,my k
<br />de ddd pt a d and 100N,
<br />staled) ++
<br />28e. baire M as<lirK
<br />to Npri "andioY krvea(palion In my opinion daedl voeurrasa(al
<br />Me lime, date and place and due td the oeuee(s) stated.
<br />. �
<br />1
<br />1 ry . , T
<br />S rlatuns Thiel 0
<br />�s 5E CONTPIIBUN�TOTHE D T , 'HAS ORGAN OR TISSUE YDONATK)N _
<br />N CONS IDERED?
<br />WAS CONS N7 GRANTED?
<br />VNkNOWN
<br />` S
<br />NO
<br />� VE$
<br />' R ( 'IPHY51 A 1, NAMEA S AN r i
<br />..
<br />Sto"phen l. Rudd MD, 301 W FBidley Ave., Grand 'Island,`N'ebr'aska 6,8808 `
<br />' 324, 4EOIE7f7AR - ..
<br />,,, - - .. , I , If — - 11
<br />326. DATE, FILE
<br />1 1
<br />RE I ST,29 1§§7YGf
<br />1
<br />I
<br />et
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