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d; Tc io4 ►! ktia" 9 cis aaoilrtad i�, `e dMnd, drdglr .fld pleases s 4a: On the Maio a eihmfprltlbn a O ihvasdol)geli In rrhl a�ilnlcn daatir dalol
<br />rip data al IMflltta tlnd;;tlte) ' • i t Ste talei�dah alas O'1#aa an , doll to the oaugge) Nti+trd. (blghrlaw:and
<br />-2a. DID TOSIA ES OoNTRISUTR Ta f2EATH? BSIt,: tldtl bkkfllLN'teR'?ISYU1 ONATICH 2IE1N CONefI]NOA01 slab. WAS 00 NSENTdRANtRG1
<br />Ph .., O YES ©NI
<br />YES MO PROSAIgt Y UNKND YES NO Not A hnsble M 26a la N []
<br />27 ME, I AN 1111134 )a DF' 4ERT(FEt ( NY8101AN;74
<br />RONOWS PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />40P C
<br />gTRAR41010NATil RR , . w / no. SATE FILED Ov REGISTRAR (Ma., Day, Yr.)
<br />' . certifies this document'to be a true ,;� y of artwr�
<br />MAY ZW3
<br />Th)s � 'gml�cor w'h le with Vital Statistics, Douglas County
<br />Health beet;, Omaha, Nebraska, Cer�ni�cpp e'l�ttus ha ,a r fgpA.Oaal ip the area. to the lets. Reproductions
<br />of this greed cestif cate are not legal)s:
<br />Date Issued: MAY 1 � �AQ9 " °, � ZCeg str�� ;� ���;�,I �'�*�• .� x�
<br />Vl
<br />S
<br />Vita)
<br />6
<br />2 0
<br />STATE OF N1I3RAil(A - DPARTM�lNT. QF HEALTH 1ANP M4JI�IAI� Sf*)RVIC>9,
<br />"�mWP
<br />5
<br />n,�
<br />1.b1l., ,.'1"t•NAMI4.1Plr + t,:..''•Mltldlri .,•.Ii *w, tulrllt► " ,, .•
<br />C
<br />sox ..,
<br />a. DATE O DEATH . zv;,Y6)
<br />Harold. ; Wa a Father 111
<br />Male
<br />may 9 20Q9
<br />�4, `WTY AND S'f 7E DR:TRltittTORY, t)R f!!OIkS1OH COUNTRY OF ■IRTN'
<br />Be. AGS -Lot Obthday
<br />6b. UNDER 1 YEAR
<br />E0. UNDER 1 DAY
<br />S. DAT1 OF BIRTH (Mo., bay, Yr.)
<br />..
<br />(YOW
<br />MOO `
<br />. PAYS .
<br />Grand 1 landr:NebrOaka
<br />Be
<br />December '17, 1940
<br />7, SOCIAL SECUWV WORK '
<br />Be. PLACE OF DEATH '
<br />508-11-1372
<br />HOSPITALi ® Inpationt OTHER: Q Nursing HomdLTC ❑ Hospice Facility
<br />Pb. FACILITY-NAM1 (U not InsWutlen, give Weal and number)
<br />❑ `E t4tpaUant '❑ Decedent'* Hann
<br />VA Medical Center
<br />❑.oDA, pgih.gap.9ly)
<br />Bo, CITY,pR Tt7 WN,OP DEATN.Ibtalade ilp Cads) ..
<br />ed. COUNTY OP DEATH
<br />.. ..� .
<br />Omaha 66105
<br />Dau lee
<br />'..9e:; ft MUDENC114tTATO
<br />ab. COUNTY
<br />go, CITY OR TOWN
<br />1V teaks
<br />a. ,'
<br />grand Island
<br />SM. STREET AND NUMBER
<br />h. APT
<br />Kg. INSIDE CITY LIMITS
<br />2907 Independence Ave
<br />%
<br />g6
<br />Yee [] No
<br />Alga MARITAL STATUS AT TIME OF OVATH: Call M N rrrh
<br />10 H ivASPOUS1 (First, NN "AN LM n) N rdfe, of [den name. .
<br />❑ MgMed, put Wended 0 Widcwad Q
<br />Mae Reed
<br />11. FAlHE14'g fNilaE (Pint MkNp¢ I+r4t,
<br />W NAME 1 4 Mpldtln
<br />Barn ,o)
<br />ards
<br />1pg
<br />1Ia
<br />9a, WEER IN UA, ARMED FORCES? 0. dabaasaervlw.lf
<br />4a. INFORMANT. 11 ..
<br />:RELATIONSHIP TO DECEDENT
<br />(Yae,Na,arAamLt yg Ob/30/b'112/2�+ 74
<br />Bet M.
<br />15. METHOD OF DIOPOBITION
<br />Ift EM A
<br />LICENSg NO.
<br />169. NAIro., Day, Yr.)
<br />©K9ilvi ©amnion
<br />0. / 1 2009
<br />Ifflommn9vn ©antam1N1,9M
<br />I'�mm�avvl. ©whadarNenrl
<br />16d. CEMETERY,, CR THSR L ON : C '•
<br />STATE
<br />Gt�n e1J'v)tsk&\,C n So
<br />Nebraska
<br />17a. .FUNERAL HOME NAME AND MAILING ADD RUB (�, ... T ,
<br />170"m Zip Code
<br />Kleine Funeral Home; 3213 W n tyre land, Nebraska ,
<br />68603
<br />r
<br />IIE W DEATH
<br />ctlon m last
<br />br atom Nl Wa nllY.ae u
<br />+siMn4erv'enmp; "M MWIi K . ba 114r"f ll N
<br />r Oil 16 Ad amN,
<br />snit' tln a gnlL l�lltl Wna11NH'KnllEerpry...,
<br />I RO 4 AL
<br />IMM " •
<br />onset to death
<br />IMMEDIATO CAUSE (Final
<br />.
<br />dlaeams atvnldlibin nkAuhing ) � +• • ��
<br />no. fh)
<br />DUE 10.OR'AS A CONS GUSNC $..
<br />I onset to death
<br />Sequentimly list conditions, If n (
<br />b) �
<br />1
<br />' /F�•,
<br />� 7
<br />•any, lPedpnp is khR erekae ""so
<br />.
<br />on line b. ". DUE TO. 09 AS ACONMUENCE tU4t... ..
<br />, onset to depth
<br />,Enter the UNOtlRLY1HO:CAUtIe a)
<br />(distlae9 arl)ty flow boomed
<br />'
<br />the 111 demo) DUE 7O, OR AS A COMMENCE OFi
<br />smite to daapt
<br />LAST
<br />�. 1
<br />iS. PART IL OTHER 81QNIFICANT CDNWTWNB ondlEOnR contributing to the death but not resulting In the Underlying cause given In PART 1.
<br />19: WAS MEDICAL "AMINER
<br />• :
<br />OR CORONER ;COW, ACTED?
<br />© YES No
<br />u.
<br />20, IF FEBIALSt
<br />[] Not Fragment within past your
<br />21s. MANNER OF DEATH
<br />Ngaral © Holmobb,
<br />' 21b. IP TRANSPORTokivN INJURY
<br />© DNVerWoratar
<br />810. W AN AUTOPSY PERFORMED?
<br />.WY1S ] NO
<br />-
<br />Q INagnant at dmo of death
<br />Aceld"t [] Pending investigation
<br />E3 Passenger
<br />1d. FINDINGS AVAILABLE
<br />❑ Not firegipiM, but pro0ont within 42 days of dead
<br />Cl ©SulaMp �] Could not be tlshrminsd
<br />©Ppdaabian
<br />TO COMPLETE CAUSE
<br />TO COMPLRrf! CAUSE pF gt'lATH7
<br />1-
<br />Q Not pmgilank, but prognant42, days to 'I year befom death
<br />[3 Other (Specify)
<br />[] YP.B WQ
<br />'QUnknown if prgsrulk within the past year
<br />-
<br />82a. DATE OF INJURY (ft, pay, Yr,)
<br />22b. TWO CF INJURY
<br />229. PLACE OFjNJURY -At home, fern; street, factory, office building, construction ;site. etc. (SPeOfy)
<br />� . s.
<br />•'
<br />f
<br />28d. INJURY AT WORK?
<br />YES ❑ NO
<br />tae. D90okIER Now 44JURY OCCURRED
<br />.
<br />22r. LOCATION OF INJURY • STREET 14' NUMOOP, APT, . No, CfTY/TOY(IN STATE
<br />ZIP CODE
<br />22a, DATE OF DEATH (Me.. Day, Yr•I 248, DATE SIGNED (Mm. Day, Yr.)
<br />24b, TIME OF DEATH
<br />-
<br />P .'..'
<br />m
<br />9
<br />-20h, DATE GNED.,1111a., pay, Yr.). no. TIME OF DEATH - 249. PRONOUNCED DEAD (M9., Day. Yr.)
<br />7 y,
<br />24d. TIME:Pit"OUNCED DP.AD .
<br />d; Tc io4 ►! ktia" 9 cis aaoilrtad i�, `e dMnd, drdglr .fld pleases s 4a: On the Maio a eihmfprltlbn a O ihvasdol)geli In rrhl a�ilnlcn daatir dalol
<br />rip data al IMflltta tlnd;;tlte) ' • i t Ste talei�dah alas O'1#aa an , doll to the oaugge) Nti+trd. (blghrlaw:and
<br />-2a. DID TOSIA ES OoNTRISUTR Ta f2EATH? BSIt,: tldtl bkkfllLN'teR'?ISYU1 ONATICH 2IE1N CONefI]NOA01 slab. WAS 00 NSENTdRANtRG1
<br />Ph .., O YES ©NI
<br />YES MO PROSAIgt Y UNKND YES NO Not A hnsble M 26a la N []
<br />27 ME, I AN 1111134 )a DF' 4ERT(FEt ( NY8101AN;74
<br />RONOWS PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />40P C
<br />gTRAR41010NATil RR , . w / no. SATE FILED Ov REGISTRAR (Ma., Day, Yr.)
<br />' . certifies this document'to be a true ,;� y of artwr�
<br />MAY ZW3
<br />Th)s � 'gml�cor w'h le with Vital Statistics, Douglas County
<br />Health beet;, Omaha, Nebraska, Cer�ni�cpp e'l�ttus ha ,a r fgpA.Oaal ip the area. to the lets. Reproductions
<br />of this greed cestif cate are not legal)s:
<br />Date Issued: MAY 1 � �AQ9 " °, � ZCeg str�� ;� ���;�,I �'�*�• .� x�
<br />Vl
<br />S
<br />Vita)
<br />
|