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' r STATE OF NEBRASKA
<br />IMHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, lT CERTIFIES THE BELOW TO BEA TRUE COPY OF THE ORIGINAL REC.Qf~2flAI.FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS~[~CH IS
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<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. -
<br />DATE DF ISSUANCE ~~;
<br />DEB 1 ~ ?_00~' Q ~`J = ~+t+Ii~.~~cD
<br />- LINEOLN, NEBRASKA ~ O O ~ 0 V ~ f ~ HE~A~T(V`Af11D MUMAIV S~~IT~r~
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<br />STATE OF NEBRASKA- fOEPARTMENT OF HEALTH AND HUMAN SERVICES~~IA_~Tfr_ -_~_- ORl
<br />("FR7IFICATF (]F DEATH °- • ~-
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<br />1. DECEDENT'S-NAME (First, Middle, Last, Sulllx) 2. 3EX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />.:• Helen Marie Thiel Female February 7, 2006
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE•Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF GIRTH (Mo., Dey, YrJ
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<br />' Sherman County, Nebraska (Yrs.) 78 MOS. DAYS HpUR3 MINS. JUIy 9, 1927
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<br />,s 7. SOCIAL SECURITY NUMBER Sa. PLACE OF DEATH
<br /> 506-28-3333 HOSPITAL ^Inpetlent 9T11E9: g]Nursing Home/LTC uHOSpice Facility
<br /> Bb. FAOILITY-NAME (If not Inetltullon~ glue street and number) _ -
<br />• O ERIOutpatient ^Dacedent'sHOme
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<br />` Tiffany Square
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<br />~ Other(Speclly)
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<br />°' w8c. CITY OR TOWN OF bEATH (Include ZIp Code) ~~ ed. COUNTY OF DEATH
<br />4 S
<br />Hall
<br />Island 68803
<br />Gran
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<br />' 9a.RE51DENCE•STATE Bb.000NTY Bc.CITYORTOWN
<br />"~'> Nebraska Hall Grand Island
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<br />- gd.STREETANDNUMSER 9e. APT. NO BL ZIP CODE 9g.IN51DECITYLIMITS
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<br />;~,. St.
<br />2313 W. lOth 68801 }C] ves~ ^ No
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<br />10a. MARITAL STATUS AT TIME OF DEATH [,Married ^ Never Married
<br />iDb. NAME OF SPOUSE (First, Middle, Laet, Suffix) If wlfa, give melden name.
<br />, Karl Thiel
<br />a ^ Merrled, but separated p Widowed ^ bivdreed ^ Unknown
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<br />~ 11. FATHER'S•NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Maiden Surname)
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<br />'= Will Kraber Agnes Vacha.
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<br /> 13. EVER IN U.S. ARMED FORCES? Glve dates of service if yes. 14a. INFORMANT-NAME 146. RELATIONSHIP TO DECEDENT
<br /> (Yes, no, Drunk.) No _ Karl Thiel _
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<br />• _ husband
<br /> 15. METHOD OF bI5PD51TI0N E 18b. LIC SE N0. 18c. DATE (Mo., Day, Yr. )
<br />18a. EMB R (GNAT
<br /> ~8urial ^gonalion ~Z ~~ February 10, 20_0.6
<br /> UCramatlon Entombment 18d.CEMETERY,CREMAT RY RO ER LOCATION CITY/TOWN STATE
<br /> ^Removel ^Olher(Specify) Grand Island Cemetery Grand Island, Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty orTown, Stale) 17b. Zlp Code
<br /> Apfel k'uneral Home, 1123 West Second, Grand Island, Nebraska
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<br />~ 68801
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<br /> 18. PART I. Enter the cheln of evants••dlseases, Injurlas, ar compllcetlons--that directly caused the death. DO NOT enterterminal events ouch ae cardiac arrest APPROXIMATE INTERVAL
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<br /> respiratory arrest, or ventricular flprlllagon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Ilnes If necessary. I
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<br />~''~•~ I onset td death
<br />IMMEDIATE CAUSE: f~. ~~y,,~~1,^~,w,-
<br />IMMEDIATECAU5E(Flnal (a) ~~,~~ vY Ur`~ _I„ 1 ~w'"~
<br /> disease orconddldnreeulting pUE T0, OR AS A CONSEQUENCE OF: I onset to death
<br /> In death)
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<br /> Sequentially llet condlllone, It
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<br /> any,leadingtothecaueelleted DUE TO, ORASACONSEOUENgEOF: I dnsettodeath
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<br /> Enterthe UNbERLYINC CAUSE
<br /> (dleeaee or Injury that lnltlatad (~)
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<br /> theevenla)eaultingin death) DUE T0, OR AS A CONSEQUENCE OF: I onset to death
<br /> LASE
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<br /> 18. PART IL OTHER SIGNIFICANT CONDITIONS-Candltlons conlrlbuting to the death but not r s Iting In the underlyl cause giv~rn In PART I, iB. WAS MEDICAL EXAMINER
<br />L'~~L •~~ ~YL•~"~" OR CORONER CONTACTED?
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<br />~Q rc+~~~` y.,l, ~~+-i.. ~ L,) YES Q N 0
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<br />~ 20. IF FEMALE: ~ 21e.MANNERO TH 21 FTRANSPORTATIONINJURY ic.WASANAUTOPSYPERFORMED7
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<br />of pregnant within past year ~T•latural ^Homiclde Driver/Operator
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<br />^YE5 ~0
<br /> ^ Pregnant at time of death ^ Accldent~] Pending Investigation Passenger
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<br />^ Nvt pregnant, but pregnant within 42 days of death
<br />U Sulclde U Could not be determined ^ Pedestrian
<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE TO
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<br />~' ^ Not pregnant, but pregnant 43 days to 1 year before death ^ Other (Speclly) COMPLETE CAUSE OF DEATH?
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<br />^ Unknown If pregnant within the past year
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<br />U YE5 U NO
<br />_i 22a. pATEOF INJURY (Mo., Day, Yr.) ~22b. TIME OF IN JURY 22c. RLACE OF ItTJURY•At home, farm; street, factory, oTllae bulldtn~ borieirud ol~fte-9Td.jSpeClfy) -- - ~- ~~ -
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<br /> 22d.INJURYATWORK? 22e.DESCRIBEHOWINJURY000URREO -
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<br /> ^ YES ^ ND
<br /> u22f LOCATION OF INJURY-STREETSNUMBER,APT.NO. _ ~_ CfTY/TOWN ~_ STATE ZIPCObE
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<br />,. 23a, DATE OF DEATH (Me., Day, Yr.) = y, 24a. DATE SIGNED (MO., Day, Yc) 246.TIME qF DEATH
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<br />DATE 51G Eb (M
<br />Day
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<br />TIME OF DEATH ~ _ ~ 24c
<br />PRONOUNCED DEAD (Mo
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<br />Yr
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<br />TIME PRONOUNCED DEAD
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<br />~ c 23d. To the best of m knowledge, death occurred at the flma, data and place ~ w
<br />249. pn the basis of examination and/or investigatlon, in my opinion death occurred at
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<br />~ end due td the cause(s) stated (Si ure and Title) ~
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<br />the dme, data end place end due to the cause(s) stated. (5lgnature end Title) ~
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<br /> ~25.bIDTOBACCOUSECONTRISUTETOTHEDEATH? 26a.HASORGANORTISSUEDONATIgNSEENCpNSIbERED7 266. WAS CONSENTGRANTED7
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<br />. ' ^YE5 ^ ND ^ PROSASLY UNKNOWN ^ YES NO Not Applicable if 25a is NO ^ YES ^ NO
<br /> 27. NAME, TITLE AND ADDRESS OFCERTIF R ( YSICIAN,CORONER'SPHYSICIANORCO NTY ORNEY) (Type orPrlnq
<br /> William Landis ~'I.D. 2444 W. ~'aidley Ave., Grand Island, NE 68803
<br />I 28a. REGISTRAR'S SIGNATURE 286. DATE FILED BY REGISTRAR (Mc., Dey, Yr.)
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