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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF.. HEALTI+L'A1~T1 l~ M,r4N~RVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA~A~tl'~'~d~(T O~:MEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY F"OR.~/I~1L•R ~$ ~ 11
<br />DATE OF ISSUANCE ~~
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<br />p r ry a~ t/NENT .QF h1EALT ~H ANA ,"'
<br />LINCOLN, NEBRASKA 2 Q O~ O S 5 I J ~*$F~IC~S F.~ ,• c, ":~
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<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH ANP HUMAN SERVICES FINANCE AND SUPgp
<br />_ _ CERTIFICATE OF DEATH ?"'''~~~~.~
<br />1. DECEDENT'S•NAME (First, _ Middle, Lest, 8uflix) 2. SEX 3. DATE DF DEATH (Md'.; fey, Yr.)
<br />Harold ,john Christ Male Octobex' 1, 2009.
<br />4. CITY AND STATE OR TERRI70RY, OR FOREIGN COUNTRY OF 81RTH
<br />Howells, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />_ 508-18-1355
<br />eh. FACILITY•NAME (II not Institufidn, glue street and number)
<br />St. Francis Medical Center
<br />[] D04 ^ Other
<br />ed. COUNTY OF DEATH
<br />Hall
<br />9c. CITY DR TOWN
<br />Grand Island
<br />9d.STREETANDNUMeER ~ Be. APT. NO gLZIPCODE
<br />1428 N. Hancock ~ fi8803
<br />10a. MARITAL STATUS AT TIME OF DEATH ~1 Married ^ Never Married 10b. NAME OF SPOUSE (First, Mlddla, Last, Su}flx) II wile, give maiden name.
<br />8c. CITY pRTOWN OF DEATH (Include Zlp Code)
<br />Grand Island 68803
<br />9a.RESIOENCESTATE 9b.000NTY
<br />Nebraska Hall
<br />^ Married, but Beparafed ^ Widowed ^ Divorced ^ Unknown Burdean S tuef er
<br />gg, IIxN, SIDE CITY LIMITS
<br />W VES ^ NO
<br />11. FATHER'S-NAME (First, Middle, Lasl, Su11iX) 12. MOTWER'S•NAME (Firs[, Mlddla, Malden Surname)
<br />_ August Christ _ _ Rose Zastera
<br />t3. EVER IN UyS. Epp R 5? Glve de1esor service if yes. t4a.INFORMANT•NAME t4b. RELATIONSHIP TO DECEDENT
<br />Yes: ~l~/f~~~l 11/8/1945 Hurdean Christ Wife
<br />(Yes, no, or un. .•~ ~-~-
<br />15. METHOD OFDISPOSITION 78s. EM8 -SIGNAT RE 166. LI SE p. 16c. DATE (Ma., Day, Yr. )
<br />~BdrlAl ^DOnallon /~~Q_ Oct. ~7, 2009
<br />16d.CEMETERY,CREMA OROTI ER LOCATION CITY/70WN STATE
<br />^Cremalicn ^Entombment
<br />^Removal ^Olher(Specify) COlumbu8 City Cemetery, Columbus, Nebraska
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<br />22d.INJIJRYAT WORKT 22e. pESGRIBE HOW INJURY OCCURRED
<br />^ YES Q N~
<br />17a FUNERAL HOME NAME AND MAILING ADDRESS (Street, City orTown, State) t 7b. Zip Coda
<br />Apfel Funeral Home, 1123 West Second, Grand Island, NE 68801
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<br />18. PART I Enter Ute ~pln Al events--diseases mlu es,or complicalion9- thai tlirectly caused rho deem. DO NOT enter terminal eve NS such ns cardiac arrest, APPROXIMATE INTERVAL
<br />re6plretary arrest, or vermicular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only ane cause on a line. Add addlllonal lines if necessary. I
<br />IMMEDIATE C I Oneet to dd,'e^at'h~p-''9-'~[/
<br />IMMEDIATE CAUSE (Final (a) _ ~ ... -- _II ~ -'•
<br />dieeaeeorronddhnrewlNng DUE TO, A A~ NSEQUENCEOF: e I onaellodeath
<br />In deatlt) I
<br />5equengelly lief COndltlona, It (b) r _ I ----.-
<br />any,leadtngtothecauaetlated ~ DUE TO, OR ASACONS ENCE DR ~ I gnset to death
<br />an Ilna a. I
<br />EmertMUNDERLYINGCAUSE /j ~~. '~
<br />(dleeaeeorln)urythatlnlllaled (°) [i vvv _. i _.
<br />the avente resulting In deadr) DUE TO, DR ASACONSEOUENCE OF: I onset to death
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<br />. PART II. pTHER SIGNIFICANT CONDI710N5•Conditions Contrlbuting to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br />/J ,. / T OR CORONER,,CJONTACTED?
<br />;r, ~ U„/><„ ~ / /A//n~~•~ (f V /off ..-. ~ ~' LV~ ^ YES Al NO
<br />lXW/llrr(l ~ ~/f ~(/ 1/LL. d~ ~gJ~.~'at
<br />20. IF FEMALE: 21a.MAN ERDFDEATH 21b.IFTRANSPORTATIONINJURY 21C.WASANAU70PSYPERFORMEDI
<br />~tural ^ Homicide ^ Driver/Dperatar -- //
<br />^ Not pregnant within past year ^ YES CYNO
<br />^ Passenger
<br />^ pregnant al time of death ^ Accident^ Pending Inveatlgatlan --
<br />^ NClpregnant, but pregnant Wlthln 42 day9 OI death ^ Pedestrian 27d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />^ SulClde ^ Could not be determined ^ Other (Specify)
<br />.^ Not pregnant, but pregnant 43 dayB lc 1 year before death COMPLETE CAUSE~OF DEATH?
<br />^ Unknown it pregnant wlthln the peel year _.,_ _ ^ YES W ND
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22C. PLACE OF INJURY•Al home, term, atr6et, lactory, office building, conslruCtlon site, etc, (SpeClly)
<br />22t. LOCATIDN OF INJURY • STREET 6 NUMBER, APT. N0. CITYJTOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.) w
<br />~' ~ oc __l~z9o9 _.
<br />~r 23b, DATE.~IONEb MO., Day, Yc) 23c, TIME OF DEATH
<br />E ~ ~ to ~' 2 , 2009 7 - 50 m
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<br />23d. Te t e befit o my knowledge, death a urred at the time, data and place
<br />' ~ and sus s) etata (Big store and Title)
<br />STATE ZIP CODE
<br />zs 24a.0ATE61GNED(Mv.,Day,Yr.) 24b.TIMEOFDEATH
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<br />SU ~ .. - _-
<br />~~~ 24c.PR0N0UNCEDDEAO(Mo.,Day,Yr.) 24d.TIMEPRONOUNCEDDEAD
<br />a~`~ m
<br />W 24e, On the bests of exflminadpn andlor invaetlgativn, in my opinion death occurred aI
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<br />~' ~¢ p the time, dale end place and due to the Cause(s) stated, (Signature and Title) •
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<br />25 DIDTOB CD ECONTRIBUTETO THE DEATHS 26a. HA9 ORGAN OR TISSUE DONATIDN BEEN CONSIDERED?
<br />^ YE NO ^ PR08A8LY Q UNKNOWN ^ YES NO
<br />' 27. NAME AN ADDRESS OF CERTIFIER (PHYSICIAN,CDRONER'5PHV51CIANOR000 YATTORNEY) (TypeaPrint)
<br />Jahn Wagoner M.D. 800 N. Alpha Ave., Grand Islar..d, NE
<br />28a. REGISTRAR'$SIGNATURE ~ _ /
<br />5a. AGE-Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY
<br />(Yrs.) MDS. DAYS HOURS MINE.
<br />87
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />February 18, 1922
<br />ea. PLACE OF DEATH
<br />HOSPITAL: Jb`I Inpamenl QT},E9: ^ NursingHvme/LTC QHOepiceFacillry
<br />^ ER10utpatlent . .. ^ Uecedent'S Home
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable ll 26a Is NO ^ VES
<br />68803 LL~~~~
<br />28b. DATE FILED 8Y REGISTRAR (Mv., Day. Yr.)
<br />qCT ~ 20Q9
<br />HMS-61 11/03 (55061)
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