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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAD ~ MAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH ThlE NEB R~1s~lYT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITOR Y~~2 V~'~L~~~t~~S~J" ~ ~'•
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<br />PATE OF ISSUANCE n s~ ~ ~,, J~.`~C,~~
<br />C 2 O O 9 O ~ 3 ~ ~ ~~, ~'Tyt NLEY . Cea~R C ~ '~, '
<br />SC~ ~ Q ZOOS '"; ~4SSI 5~ REYa~StfiR~R
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<br />LINCOLN, NEBRASKA ; ~~ "~ll1~FAN .~ERVICE~ - ,~; .~" "
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<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAR~6E1}~/ID~~. r ~ ~ c" "
<br />1. DECEDENT'S-NAME (Flret, Mlddle, Last, SuHlx) 2. SEX a ~ pQTJ._ OP. Ty, .,pay,Yy:) ~ ',
<br />Donald Herman Muhs Male ~ ~~t f~'s8;°'2Q08
<br />i 4. CITY AND STATE OR TERRITORY, OR FpREION COUNTRY OF BIRTH 5a. AGE-Last Birthday 6b. UNDER 1 YEAR 6c. UNOER T DpY~ 8. BATE OF BIRTH (Mo., Dry, Yr.)
<br />(Yre.) MOS. DAYS HOURS MIN$: -
<br />Hall County, Nebraska 75 January 7~ 1933
<br />L SOCIAL SECURITY NUMBER 8a. PLACE qF DEATH
<br />505-36-4079 HOSPITAL: ©Inpetlent ,OTHER; [] Nuroing Hgme/LTC ^ Hospice Facility
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<br />f'° Bb. FACILnY-NAME (If not Inatltutlon, glue street and number) ^ ERlqutpstlent ^ Decedent's Hama
<br />^ DOA ^ Other(8pecify)
<br />Saint Francis Medical Cgnter
<br />Bc. CITY OR TOWN OF DFJITH (Include Zlp Cade) Bd. COUNTY OF DEATH
<br />~ Grand Island 68803 Hall
<br />Z 8a, RESIDENCE-STATE eb. COUNTY >k. CITY OR TOWN
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<br />~, Nebraska Hall Grand island
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<br />~p Yd. STREET AND NUMBER 9e. APT. NO. 1N. ZIP CODE ep. INSIDE GITY LIMITS
<br />w 254.South Plum 68801 ®vee ^ No
<br />~ 18e. MARITAL STATUS AT TIME OF DEATH ®Mamed ©Navar Married 7qb. NAME OF SPOUSE (Pint, Middle, Last, Suffix) If wife, plus maiden name.
<br />~ ^ Marcied, but separated ^ widowed ^ Divorced ^ Unknown Dolores ,Eleanor 5tefangwicz
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<br />E 11. FATHER'S-NAME (Flroe, Mlddle, Lael, Sufrlx) 1T. MOTHER'S-NAME (Flnl, Middle, Maiden Sumeme)
<br />va Herman Muhs Hilda Reher
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<br />m 78, EVER IN U.S. ARMEb FORCL57 Olva dates oT rervlce If Yea. 14a. INFORMANT-NAME 146, RELATIONSHIP TO DECEDENT
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<br />(Yee, No, or Unk.) Ye$ 02i11i1953-0211011955 Dolores Muhs Souse
<br />16. METMOD OF DISPOSITIDN 18a. EMBALMBH-SIGNATURE 186, LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />®9uAs1 ^°°"tll°n ~ ~ ~ c<-~..~7 '~ _ ....p ~~ ~~9 % Se tember 2, 2008
<br />©cnmedon ^Emomem.nt -
<br />^RSmoval ~othegepecxyl 18 EMET RY, CREMATORY OR OTHER LOCATION CIT.YROWN STATE -
<br />Westlawn Memorial Park Grand Island Nebraska
<br />17e. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clry or Town, State) 17b. Zip Code
<br />All Faiths Funeral Wome, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH Bee Instructions and exam les
<br />ts. PART L Enur tlls - dlussee, INunse, qr campllwtlgns-ehN directly uwsd me dMlh. n0 NqT enblr plminel rnnu such u cerdisc ernq, APPROXIMATE INTERVAL
<br />naglfMOry amaR or venMculer flbrlllxtlon whhaul ahPwln® the etigtgay- b9 NOT ABBREYMTH. Enta1'aNy wra reap on a xnaAdd.d4xlonal Mnra x neGi~02aly. - - .~ - ~ - ~ I
<br />IMMEDIATE CAUSE: I onset to death
<br />IMMEDIATE CAUSC (Final ~~ ~ (A (~ .7 H rQ ., ~ _ /
<br />tllaeaee or conditlan rosuhing a) J v ~ .
<br />in dnth)
<br />DUE TO, OR AS A CONSEQUENCE,OIF: onset to death
<br />Sequen8ally Ilet conditions, If b) ;~f /~ ~,~~w I p ~ ~ s~ I --~1
<br />any, leading to the cause lleled P v C
<br />an Ilns a. DUE TO, OR A$ A CONSEOUENCE OF: onset to death
<br />I
<br />Enter the UNDERLYING CAUSE c) I
<br />(dlawe or InJury that IDltlated
<br />~ the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />EAST I
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<br />10. PAR711. OTHER SIGNIFICANT CONDITIONS-Conditions conMbutlnp to the death but not resultlng In the undarlyinq cause given In PART 1. 18. WA8 MEOICpL EXAMINER
<br />r S ~/'/~~ OR CgRONER GONTACTED7
<br />tY
<br />W 20. IF FEMALE: 21a. MANNER OF pF11TH 21b. IF TRANSPORTATION INJURY T1c. WAS AN AUTOPSY PERFORMED?
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<br />1= ^Not pregnant within past year atural ^ Homicide ^ DrlvarlOperetor ^ YES (~altT
<br />^ Prognant at time qT death [] Accident ^ Pandlnp Imaatlpatlon ^ Passenger 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />~ ^ Not pregnant, but pngnent wllhln 4T days of death ^ Suicide ©Could no! 6e determined ^ Pedestden TO COMPLETE CAUSE OF pEATH7
<br />^ Not pngnent, but pngnent 43 days to 1 year 4efore death ^ Other (Specify) ^ YES ^ NO
<br />^unknawn IT pngnent wllhln fhe past year -
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<br />TTa. DATE OF INJURY (Mo., Day, Yr.) 2Tb. TIME OP INJURY TTc, PLACE OF INJURY-At home, farm, aunt, Taclory, office pullding, construction site, etc. (Specify)
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<br />. -.- - m 31d. iN3tlR~" A'r WORItt~ ~ iTe. DESCRIBE N01A/I I~JUttY'OL'~'URREb'~'i~~~.y~~~%~-.
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<br />~ ^ YE3 ^ NO
<br />TTf. LOCATION OF INJURY - 37REET 6 NUMBER, APT. NO. CITYITpWN STATE ZIP CODE
<br />Taa. GATE qF DEATH (Mo., Dsy, Yr.) x T4a. DATE STONED (Mo., Day, Yr.) T46. TIME OF pEATH
<br />~'~ Au ust 28 2008 ~~~bppi'~~ m
<br />} 236. DATE SIGNED (Mo., pay, Yc) T7c. TIME OF DEATH ~ ~ ~ T4c. PRONOUNCED pPJlq (Mo., Pay, Yr.) Tod. TIME PRONOUNCED DEAD
<br />=co 9. 2^Zao~ 2;30 p m ~~ao m
<br />.o Tad. To the best of mggqqyuwwukeenqqqqowledg~, th occurred at the time, date and place I,y ~ Toe. OP eha 6ae16 of examination Andlor InVesdgetlon, In my opinion death attuned
<br />and due to e c (s) slat ignatura and Title) ~ ~ U at the time, data and place end due to the cause(s) stated, ($Ipnsturo and Tlda)
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<br />Te. DID TOBACCO USE CONTRIBUTE TO THE D TH7 TBa. HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREO7 T86. WA$ CONSENT GRANTED?
<br />_ [] YES NO ^ PROBABLY ^ UNKNOWN ^ YE5 ~ O Not gppllcable H TBa le NO ^ YES ~NO
<br />T7. NAME, TITLE ANb ADDRESS OF CERTIFIER (PWYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type ar Prinq
<br />Gary Sett'e M.De 2116 W. Faidle Ave. Grand Tsland Nebraska 68803
<br />Tea. REGISTRAR'S SIGNATURE - TBb. BATE FILEp BY REGISTRAR (Mo., Day, Yr.)
<br />P ~- SAP ~ 2oas
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