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2 0 o s o o s s 7 StAtE OF NEBRASKAI- DEPAR'rMEN'r OF HEALTH AND HUMAN SERVICES 3 ~ ~ ~ [~
<br />CERTIFICATE QF ~ ATH
<br /> 1. DECEDENT'S-NAME (FIrs4 Middle, Lesq Sufgrr) ~ 2. SBX s. DATE aF HEATH (Me.,oey,Yr.)
<br /> Jnhn Ludwig Tagel Male Ma 7, 2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FDREIpN COUNTRY OF BIRTH 6e. AbE-Lrst Bbthdsy 66. UNDER 1 YEAR 6c. UNDER 1 DAY 6. DATE OF BIRTH (Mn., Dey, Vr.)
<br /> (Yrs.) MOS. bAYS HOURS MINE.
<br /> Norfolk, Nebraska 64 November 17, 1944
<br /> 7. SOCIAL SECURITY NUMBER Be. PLACE OF DEATW
<br />~ St]t3_~Q_~Q33 HOSPITAL: ®Inpeuant OTHER: ^ Nureing Home7l.TC [] Hnsplcs Facility
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<br />$b. FACILITY-NAME pf nnl Insdtudan, give atraat end number)
<br />(~ ER/0utpedeM ^ Dscaderd's Home
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<br />VA Medical Center (] DOA i] Othar(Specity)
<br /> fc. C17Y OR TOWN DF DEATH (Include Ylp Cvds) tld. COUNTY OF DEATH
<br />m Omaha 68105 t)au las
<br />~ fe.RESIDENCE-STATE 96. COUNTY fa CITY OR TOWN
<br />IL
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<br />Nebraska
<br />Hall
<br />Grand Island
<br />.p fd. S7RE6T AND NUMBER fa ApT. ND. ff. ZIP CODE fg. INSIDE CITY LIMITS
<br />!~ 2708 West Lamar Avenue 88803 ®Yee ^ Nn
<br />d 1fe. MARITAL STATUS AT TIME DF DEATW ®Mprtiad ^ Never Msrded tfb. NAME OF SPOUSE (First, Middle, Lesf, $Yme) If wife, giw mdden name.
<br /> __L}."n'"f°'°°`~°n-•Q -°'"°'°'~'~}+~r°"" Pan-ela M Vnikl
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<br />e 77. FATHER'S-NAME (Flrsq Mlddls, Lsaf, Sunlx) 7Y. MOTHER'S-NAME tFlfbt, Middle, Malden Surrrame)
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<br />Ludwi V T el
<br />Loretta Thramer
<br />Bll 13, EVER IN D,S. ARMED FORCES? (live dstea yr service If Yee. 14e. INFORMANT-NAME 144. RELATIONSHIP TO DECEDENT
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<br />(Yoe, Nn, or unk,) Yes 05 '25 b4-C)5 0 65
<br />Pamela Ta ~'
<br />Wife
<br /> 16. ME7Hpb pF bl$PO$ITX)N 16a. EMBA IGNATURE 1fb. LICENSE NU. 18c, DATE (Mo., Dey, Yr.)
<br /> ©BUrlel ^DOrretien .,..~.~---~- ~~~ Ma 1z, zoos
<br /> ®cnmellon ©Emomsment
<br /> []a.m.~el ©ah.hep.~lryl d. TERY, CREMAt Y OTHER LOCATION CnYITOWN STgTR
<br /> Central Nebraska Cremation Services Gibbbn Nebraska
<br /> 17e. FUNERAL HOME NAME AND MAILING ADDRpSS (Street, City or Town, Stele) 77b. Zlp Code
<br /> Peters Funeral Hame, 302 Second Street, PO Brix 181, St. Paul, Nebraska 88873
<br /> CAUSE OF DEATH See instructions and exam lea)
<br /> f e. PAh11. Sneer the pDNn Wiventr - d1eM~ee, iWprMe, er 6emprlCellone- Nnt dhectly eeupd the death. 00 NPT engrM~minel ew111e suce se cerwee erren, ~ APPROXIMATE INTERVAL
<br /> reeplrerery erreet, or venlrleuMr Ohrlllnlun wllheur showing Ilrc eNele ft'. DO NbT ABBREVIATE. Entpr only eue Ceuee en s Hue. Add eddelerrd fnea X neeea~ery,
<br /> IMMEDIATE CAUSE: i onset tv death
<br /> IMMEDIATE CAUSE (Final i ~/ l L
<br />dl4ease ar norWidvn resulting s)
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<br /> P ~. e v rn ~ r, Tit i ~ 1 '~ b ,10 ~
<br />~s
<br /> in death)
<br /> DUE TO, OR AS A CONSEgU@NCE OF: i onset ev death
<br /> $equsnllslly Ilal conditions, K r pp 1.,- r
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<br />any, IvadingMtlre ceuas listed
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<br /> on Ilne e. bUE 70, OR AS p GDNSEOUENCE DF: r onset tv derth
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<br /> Enter the UNOERLYINO CAUSI. e) r
<br />=dio el'~ic ~vl wlnwav ~l~btySis ~ ~ rs
<br /> (dlaeeee or InJury that I1Aitleled
<br />the events resulting in dealli) DUE Tq, DR A$ A CDNSEgUENCE OF: r amet lv death (
<br /> LAST i
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<br /> 18. PART h. OTHER 31GNIFIGANT CONOITR7NS-Conditions contributing tv the death but not resulting M the underlying Coosa given In PART 1. 79. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTAC7t?47
<br /> ^ YES [~!O
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<br />W Yll. IF FEMALE: Y1a. MANNER OF DEATH Ytb. IF TRANSPORTATION INJURY Z7c, WAS AN AUTOPSY PERFORMEb7
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<br />^ Not pregnant within past year
<br />'r~Nsturel ^ Wvmlclds
<br />^ DrlverlOperetor
<br />E3 ^ NO
<br />W ^ Pregnant st lima of death ^ Accident ©Psnding Investipedon ^ Peeeengsr Y1d. WERE AUTOPSY FINDINGS AVAILABLE
<br /> ^ Nol pregnant, but pregnant within 4Y days of death ^ Sulelde ^ Cnuid not ba delerrMned Q padestdrn TO COMPLETE CAUSE OF DEATH?
<br /> ^ Nn! pregnant' 6u! pregnant 4a days tv 7 year 6efnre death ^ Other (Speclty) ©VE9 ®~l0
<br />~ ^Unknown If pregnant within the past year
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<br />YYe. DATE DF INJURY (Mv., Day, Yr.)
<br />YYb. TIME OF INJURY ~
<br />ZYe. PLACE dF INJURY-A! hvrrN,.farm, street, Tactary,.alfks bWlding, aonstrucgon ails, ale. (Spaclty)
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<br />~ YYd. INJURY AT WORKS
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<br />^ YES ©NO YYe. DESCRIBE HOW INJURY OCCURRED
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<br /> YYf. LOCATION OF INJURY - STREET i NUMBER, APT. NO. CITYITOWN STATE ZIP CDD6
<br /> 28e. DATE OF DEATH (Mo., Dey, Yr.) ~ 20s. bATE SIONEO (Mn., Day, Yr.) 24b. TIME DF DEATH
<br /> .~'~ Ma 77 20DQ' $~~ m
<br /> pp 23b. GATE SIONEb (Mo., bey, Yr.) YYc, TIME OF DEATH ~ Z4c. PRONOUNCED DEAb (Mo., bay, Yc) Y4d. TIME PRONOUNCED bEAb
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<br />FF~1 2004 ~v: As- m dz m
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<br /> best IS-my kntiwlndge
<br />death necuned al the Bms
<br />date and place
<br />re $ y~y~7 ~ Yoe. tln the baste yr exsminlUvn andlvr InvesNgadvn, In my opinion death occurred
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<br />(Signature end Tllle)
<br />~ " end
<br />the teuse(s)atafed $ Z ~ et the lime
<br />date and piece and due to Urs cause(s) staled. (Signaluro and Tllle)
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<br /> p U E CONTRIBUTE'tp TFt>}' DEA7H'~-'"'
<br />!f. DID.T Yfa. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERtA9 26b. WAS CONSENT GRAN7Eb7
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<br />^ YES. ~] N~:e;" ^ PR09A,~LX ~ UNKNOWN ~.
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<br />^ YE8 ~ NO
<br />Not Appllubls M Yfe Is NO ^ YES ^ NO
<br /> ME; TI?LE,AND ADD(~ES® C~itTlRleli (PHYSIGU4N, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type nr pHnq
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<br />2fb. DATE BLED BY RE
<br />GISTRAR
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<br />This certifies th~ document to he a true copy of an original record on file with Vital Statistics, Douglas Cout7ty
<br />Health Dept., Otnaha, Nebraska. Certified copies must have a raised seal ill the area to the left. Reproductions
<br />of this green certificate are not legal copies.
<br />I"p '^~,,
<br />Date issued: ~~Y ~ 2 ~p~~ Registrar: ~~ ~°"~ ,,,,..
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