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• STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALT-I ANA
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASK64~
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITA, L•~
<br />DATE OF ISSUANCE ~
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<br />N SERVICES, IT CERTIFIES
<br />7i1~ OF HEALTH AND
<br />APR 2 2 2009 2 0 o s o 4~ 2 i ~,~ ~" ~µ~~.w, ..
<br />~SStS7"AN ~5,1'~z ".~
<br />DEPRI~TMf~~~.. !.{~ ANDS µ
<br />__.. LINCOLN, :NEBRASKA HUM,4/V 5G-1rt4~I'CE~S
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<br />STATE OF NEBRASKA - DEPARTMENt OF HEALTH AND HUMAN SERVICES ~~ ~ _ s
<br />\I CFR71FICaTF AF 1-fFATH ;'' ~ ~ .
<br /> 7. DECEDENTS-NAME (Piro!, Mlddle, Loaf, Suffix) 2. SEX S. DATEQF DEATH (, o.,Day,Yc)
<br /> Elinor Marjorie Harms Female Aril 11, 2009
<br /> 4, CITY AND STATE DR TERRITORY, OR FOREIpN COUNTRY OF BIRTH Ba. AGE-Last Blrttrdey 66. UNDER 1 YEAR 6c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (YnJ MOS. DAYS HOURS MIN$.
<br /> Battle Greek, Nebraska 84 June 13, 1924
<br /> 7. SOCIAL SECURITY NUMBER la. PLACE OF DEATH
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<br />505-26-7931
<br />NosP1TAL: ^ Inpadent Q711ftt; ®Hunlny HOmNLTG ^ Haaplce Faclliry
<br /> Bb. FACIUTY•NAME (N nol Inedtutlon, ylre atroet and number) [~] ER/putpafimt ^ Deced-nl's HOlrie
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<br />Lakeview-A GDiden Living Genter ^ DOA ^ Othar(Specify)
<br /> 8c. CITY OR TOWN OF DEATH (Include Zip Code) Bd, GOUNTY OF DEATH
<br /> Grand Island 68801 Hall
<br />~ 9a. RESIPENCE•STATE Bb. COUNTY Bc. CITY OR 70WN
<br />~, Nebraska Hall Grand Island
<br /> tkt. STREET AND NUMBER 8s. APT. ND. W. ZIP CODE 8g. INSIDE CITY LIMITS
<br /> 1405 W. Hwy 34 68801 ®Yaa ^ No
<br /> 16a. MARITAL STATUS AT TIME OF DEATH ®Marrlsd ^ Nsvsr Marrlsd 186, NAME OF SPOUSE (Flrat, Mlddle, LaaL BuTNx) R wife, plus maiden none.
<br /> ^ Mewled, but eeparehd ©widowW ©Dlrara.d ^ unknown Robert William Frederick Harms
<br />~ 11. FATHER'S•NAME (First, Middle, LaaL Sumx) 12. MOTHER'S-NAME (Pint, Middm, Maiden Surname)
<br />~ Geor e E en Amalie Oettin
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<br />m 18. EVER IN U.B. ARMED FORGES? 61w data OT service If Yea. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
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<br />(Yea, No, vrUnk.) ND
<br />Robert William Frederick Harms
<br />Husband
<br /> 16. ME7NOb OF DISPOSITION 1 a. E ALMER-SIGN RE 18b. LIGENSE NO. 18c. BATE (Mv., bey, Yr.)
<br /> ®°u"" ^°ane1on G' ~U~~ Aril 16, 2009
<br /> ^Cnmetlan ^Entomemint
<br /> ^Rim°vu ^vehiryapiexy) 18d. CEMETERY, CREMATORY OR OTHER LOCATI CITYlTOWN STATE
<br /> Westlawn Memorial Park Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS ($troet, Clfy or Town, State) 17b. Zip Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />_ .. __. _ _. CAUSE OF I]EA7H SPe in~ltructdons and exam les
<br /> 1e. PMT 1. Emir IillelAaf,.t~tlY - dlaewi, INunii, a cvmplk..aon+-mN dlmelty nuwd w dWn. Dv NOT ~nt.f wmin ewnn /uck ae araea arnp, l APPROXIMATE INTERVAL
<br /> niplnnry erm4 ar wmrlculxr Bbdlleavo nrlthvut ihvwinq ihr NI°logy. Do NOT AQDRCV WTC emir only om uua on ^ Ifni. Add eddldonel Ilma It Mgw11ry. 1
<br /> IMMEDIATE CAUSE: ~ onset t0 death
<br /> IMMEDIATE CAUSE (Final .y ~ • ~
<br />disease or com8don rosulUnp a) ~
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<br /> ~ ~ a-c~+~~ r
<br />In death) 11
<br /> DUE TO, OR A$ A CON QUENCE OF: ~ onest t0 death
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<br />Sequmtlelly Ilat candidana, H r
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<br /> any, leading to the cause Ilated
<br /> on Iina a. DUE TO, OR AS A CONSEQUENCE OF: ~ Onset to death
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<br />Enter the UNDERLYING CAUSE nl r
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<br /> (dlaeaae or Injury that inidated
<br />the ewnte reaulimp to death) DUE Tp, OR A$ A CONSt?gUENCE OF: r onut to death
<br /> LAST ~
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<br /> butinp to the death bul nut naultlnp In Nu underlying cause given In PART I.
<br />NS-CondiRon
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<br />18. PART IL OTHER SIGNIFICANT C N 16. WAS MEDICAL EXAMINER
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<br />C ~~. OR CORONER CONTACTED?
<br />^ YE$ ~ Np
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<br />20. IF FEMALE:
<br />sta. MANNER OF DEATH
<br />276. IF TRANSPORTATION INJURY
<br />21c. WAS AN AUTOPSY PERFORME09
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<br />pngnant within past year
<br />~Nktunl ^ Homicide
<br />^ pdvedppantor
<br />^ YES NO
<br />~ S
<br />Pra non! at time of Berth Accident ^ Panding Inwetlpadon ^ Passenger 21d. WERE AUTOPSY FINDIN68 AVAILA$LE
<br />a.1 ^ Nat pregnant, but pregnant within 4s days oT death ^ Sulclda ^ Could not be detamtined ^ Pedeatdan TO COMPLETE CAUSE OF DEATH?
<br /> ^ Not pregnant, but proBnent 41 days to 1 year before death ^ Other ($pedTy) ^ YES ^ NO
<br />~y ^ Unknown IT ptegnrnt within the peat year
<br />
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<br />ssa. DATE OF INJURY (Mn., Day, Yr.)
<br />ssb. TIME OF INJURY
<br />ssa. PLACE OFINJURY-At home, term, stroaL bctory, oRlce building, construction alto, etc. (Specify) ..
<br />
<br />
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<br />~ ~,Zd, INJURY AT WORKT
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<br />^ YES ^ NO ass. DESCRIBE NOW INJURY OCCURRED
<br /> 2sT. LOCATION OF INJURY -STREET 6 NUMBER, APT. NO. CITYlTOWN STATE LP CODE
<br /> sea. DATE OF DEATH (Mo., Dey, Yr.) 24a. DATE $IANRp (Ma., Dry, Yr.) ,, R46. TIME OF DEATH
<br /> ~'~ April 1 1 , 2009 ,~~~ m
<br /> °~ ~ sad. PATE $IpNEb (Ma., Day, Yr.) sac. TIME OF DEATH ~ ~ O 24c. PRONOUNCED bFAb (Ma., Dey, Yr.) tad. TIME PRONOUNCED DEAD
<br />i
<br /> Eai c. `'~ 9:05 .m. EyatO m
<br /> s.v ~ tad. Tot bast 'my knowledge, death occurred se the time, data and piece ~ W ~ 24e. On the baala of examination andlor invsatlgadan, in my opinion death occurred
<br />neture and TIUe)
<br />nd due to the cause(s) stated ($I
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<br />a ~ ~ rrrd due to the csusa(a) stated. (Signature and TIUs)
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<br /> 26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 8a. HAS ORGAN OR TISSUE pONATIpN BEEN CONBIDERE07
<br />s 26b. WAS CONSENT GRANTEb7
<br />NO ^ YES ~ NO
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<br /> ^ YES p ^ PROBABLY ^ UNKNOWN ^ YE$ O No! Appl
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<br /> 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br /> William Landis M.D. 2444 W. Faidle Ave., Grand Island, Nebraska 68803
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<br />P sBe. REGISTRAR'S SIGNATURE
<br />d s8b. DATE FILED BY R~l~`{9~y(tAg (~, ~X,yr~
<br />1!1\ 1 uul~
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