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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES .THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WM/CH /S
<br /> THE LEGAL DEPOSITORY FOR VITAL RECORDS.
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<br /> DATE
<br />F ISSUANCE ;,
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<br /> ASSISTAh~tE~' F~'EC~$TiIfA
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<br /> LINCOLN, NEBRASKA ~
<br />HEAD'Fd~NLIlA41AN;>~ERII)'/1~6~ ,
<br /> STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVII,t~$ ~"~ ' (~ ,,,
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<br /> 1. DEGEDENTS•NAME (Pint, Middle, Last, Suffix) 2.8EX ~~. ,c(:;.
<br />, 3.GgTE OF D o.,Da r.)".~
<br /> Arnold Frederick Vieth Male ~~ a 2 ~Qh,~B"r '~
<br /> 4. CITE AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 6s. AGE•Lwt Birthday eb, UNDER 1 YEAR 6c. UNDER 7 DAY ~' 6, A y I H''tl~o,~Dey,.]~f.)
<br /> (Yea,) MOS. PAYS HOURS MINS.. ,'~l • W t. ?; ,,v* 6
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<br /> Merrick County, Nebraska 80 May 1;,-1927`
<br /> 7. SOCULL SECURITY NUMBER !N. PLACE OF DEATH
<br /> 5D6-32-8150 HOSPITAL: ^ Inpatlant OTHER: ®Nuninq Home/LTG ^ Hospice Facility
<br />i~ 86. FACILITr-NAME (H not Inatitutian, piva atroet and numder) ^ ERrOutpatlent ^ DacedanNr Ham.
<br />~ Tiffan Square Care Center ^ ppa ^Othsr(Spaciry)
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<br />Bc. CITY OR TOWN OF DEATH pnWude Zlp Coda) __.
<br />Bd. COUNTY OF DEATH ~. -........ _
<br />w Grand Island 68803 Hall
<br />Z 9e. RESIDENCE-STATE Bb. COUNTY 9c. CITY OR TOWN
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<br />Nebraska
<br />Hall
<br />Grand Island
<br />~p 9d. STREET AND NUMBER 9e. APT. NO. tif. ZIP CODE 9p. INSIpE GITY LIMITS
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<br />'s 3430 E. Bismark 88801 ®Y.a ^ Ne
<br />~ 10a. MARITAL STATUS AT TIME OF DEATH ®Merrlad ^ Nwsr Married 10b. NAME OF SPOUSE (Firot, Mlddle, Lw; Suffx) If wife, Slve maiden name.
<br /> ^ Mamed, but wparabd ^ Widowed ^ DWOrced ^ Unkngwn
<br />~ Irene Michalski
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<br />11. FATHER'8•NAME (Piny Middm, Laat, Sulflx)
<br />12. MOTHER'S-NAME (Flrot,
<br />Mlddle, Malden Sumrmr)
<br />~y Hen Vieth Clara -Bove
<br />m 1S. EVER IN U.B. ARMED FORCEST Glve dater of eervlce I(Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
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<br />~ (Yea, Np, ar unk.) No Irene Vieth Wife
<br />16. METHOp OF DISPOSITION 18a. EMBALM RSIGNATUR~- 164. LICENSE NO. 18c. DgTE (Mo., Day, Yr.)
<br />®tledel ^Deneuen ~~ c4.r 1.t7 ~.......... ~' 1 3 9 7 0 2/ 2 5/ 2 0 0 8
<br />^Cromdlon ^Emombment
<br />^Removal ^OtheA8pedN) tad, CEMETERY, CREMATORY pR OTHER LOCATION CITY/TOWN STATE
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESa (Strwt, Clty or Town, State) 17b. Zip Cvde
<br />All Faiths Funeral Hpme, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE QF pEATH See instructions and exam Iss
<br />1t. PART 1. EMer the yAt(p a °wdg - dleeewa, inju,Ne, yr cvmpnc.dvnr- thn dinctly cauew the wafh, DO NOT emer Nmllnal enMa each u cvrdlxc emn, ppPRQXIMgTE INTERVAL
<br />mpintory arveet, w ve,drlculer Rhdlledon vdtnout ehowlna me aevlvey. OO NOT ABBREVwTE. Enter only vm ceua on • line. Add wdmvnq Ilse K mceewry.
<br />IMMEDIATE CAUSE: I onset tv death
<br />IMMEDIATE CAUSE (Final A ~ I ..
<br />tlr.d 1b)rconditivnroaultlnp s) ~O1/Vr~^,Q~ ,W_... ~~ ~ Cv ns`~ , I l M~~f ~!.
<br />DUE TO, OR AS A CONSEQUEN r 1 CC ' ~L d`~'r I onwt to death
<br />Sequentlally list condltlons, H b) ,
<br />any,laadlnptothecauaeliated ~L~TL~ •f3econdar t:o €all I
<br />on Ilne a. DUE TO, OR AS A ONSIEQUENCE OF: ~, anwt t0 death
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<br />Enter the UNDERLYING CAU5E c) ~ ~ (__ I
<br />(diwaae ar Injury that initiated
<br />the events raaultlnp In death) DUE TO, OR AB A CO SEpUENCE OF: onset to death
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<br />1B. PART IL OTHER SIGNIFICANT COND171CNS-Cvnditlana contrlbuGnp to the daatn but not naulUnq In the undedying c.uas plven In PART I. 19, WAB MEDICAL EXAMINER
<br />(~~7 / / OR RONERCONTACTEDT
<br />1 ~ ~.. ~ ~ !G rl 1 ~C (~ t7S M'l C'~1 J•-t ~Lt 6'q'] C''igr-1 ~ r7.~q[. jr YES ^ NO
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<br />~ 20. IF FEMALE: 21a. MANNER OF DEATH 216, IF TRANSPORTATION INJURY 27 c, wA8 AN AUTOPSY PERFORMED?
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<br />~ ^ Not propnent within peat year nF ^ Homicide [] Ddvrdpperelor ^ YES (d N0
<br />W ^ Pngnrnt at time oT death Accident ^ Pendlnp invwtlpMlon ^ Pasaanpar
<br />U 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />^ Not prognant, but preynent within 42 days Dr death ^ Suicide ^ Gould not be dstennined ^ Padaatrlan TO COMPLETE CAUSE OF DEATH?
<br />^ Not pnpnant, but prognant 47 days to 1 year daforo death ^ Other (Speclry) ~ ^ YES ~Np
<br />^Unknown if pnynant within fhs past ywr
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<br />22a, pATE OF INJURY (Mo., Dry, Yr.) 22b. TIME OF INJURY 22c, PLACE OF INJURY-At home, Tartu, atroet, factory, afiicv bulldlnp, conatructlon cite, etc. (Spaciry)
<br />la/o4/2007 lsoo rtom~
<br />0 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />I- ^-Yt=s ~glvo coughing spe11 led to syncope rand fall
<br />224 LOCATION OF INJURY - STREET b NUMBER, APT. NO. GITYlTOWN STATE ZIP GODS
<br />3430 E. Bismark, Grand Island, NE 58801
<br />23s. DATE OF DEATH/Mv., DaOYr.L ~ } 24a. pATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATN
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<br />rn 23b. DATE IGNE Mo~ay, Yr.) 2Sc. TIME OF DEATH g+ > O 24c. PRONOUNCED DEAD (Ma., pay, Yr.- 24d. TIME PRONOUNCED DEAD
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<br />y y 23d. To the b t my owladpe, death occumd at the lima, data end place ~ b~j ~ O 24e. On the bash or sxeminsUon wd7or Inveetlyatlan, In my opinion death occumd
<br />e ~ and dui to au e(a) stated. (Signature and TIUe) g z O at the lima, data and place and due to the cauae(a) stated. (Stgnrtun and TIlIs)
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<br />25. ID TOBACCI~E CONTRIBU O THE DEATHT 28a. HAS ORGAN OR TISSUE pONATiON BEEN CONSIDEREb7 28b. WAS CONSENT GRANTEDT
<br />YES ^ NO ^ PROBABLY ^ UNKNOWN ^ YES ~ NO Not Applicable If 28a la NO ^ YES ^ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN pR COUNTY ATTORNEY) (Type or Print)
<br />Travis Hageman, M.Der 729 N. Custer Ave., Grand Island, Nebraska 68803
<br />28a. REGISTRAR'S SIGNATURE Rsb. pATE FILED BY REGISTRAR (Mo„ Day, Ya)
<br />P` ,. ,~. ~~q ~ 2 zags
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