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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL DF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE Qf~9GlNArL~F?@t3Cf~f.JLE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ~Tq~~ ~EG'T~3~1, ITCH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - - = _
<br />DATE OF ISSUANCE Y
<br />MAa 21 zoos 2 0 0 9 4.9 5 0 9 ~~~ ~ -~ ~i!{Iff,~-E3' S. EtSO~?ER
<br />sraivr sT~trE i~ECEST~AR
<br />LINCOLN, NEBRASKA J"I~L'TF7~ANid;IIUA~AAjaER.$~ES
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<br />STATE OFNEBRASKA - DEPARTMENT DF WEALTH AND HUMAN SERVICES FINA(~ic~,ND SUPPQ~i~
<br />CERTIFICATE OF DEATH .'. (~)
<br />"'•"? m1. DECEDENT'S-NAME (First, Middle, Lest, W Su11Ix) 2. SEY~~ 3. DATE OF DEATH (Mo., bay, Yr.)
<br />~~~ ~~' Evelyn Louise Taubenheim Femal 12 , . 207
<br />,~~ 4. CITY AND STATE OR TERRITORY, OR FDREIGN COUNTRY OF SIpTH 5a. AGE-Lest 8lrihday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., pay, Yr.)
<br /> (Yrs.) MOS. bAYS HOURS MINS.
<br />I:~:~'• NaIDpBy Idaho 65 June 4, 1941
<br />'r 7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />' -"-.._.-^~•.-..--f~-.---`-- ~}I(~SPj70L: [~lnpaifant "... ~(F„~. I~Plursing HomelLTC ^Hvspice Facility...
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<br />8b. FACILITY•NAME (II not institution give street and number)
<br />^ ER/Outpatient Cl Decedent's Home
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<br />_ Good Samaritan Center
<br />p Dp4 ^ Other (Specify)
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<br /> Ac. CITY OR TOWN OF DEATH (Include Zlp Code) ed. COUNTY OF DEATH
<br />r Kearney, 68848 Buffalo
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<br />r~J 9a. RESIDENCE•57A7E 9b. COUNTY _ Ac. CITY Op70WN
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<br />Vi'i'? Grand Island _
<br />Nebraska Hall
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<br />gd. STREETAND NUMBER ~ 9e. APT. NO 8f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />;r lfip7 Nor>:h Park AvenuE 68E303- Ct YES ^ NO
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<br />1Da. MARITAL STATUS AT TIME OF DEATH ~ Married ^ Never Married 1Db. NAME OF SPOUSE (First, Middle, Last, Suffix) II wile, glue maiden name.
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<br />G Marled, but separated ^ Widowed ^ Divorced ^ Unknown Maurice Dean Taubenh®im
<br />' ~ ,~ 11. FATHER'S-NAME (First, Middle, Last, Sufllx) 12. MOTHER'S-NAME (Flrat, Middle, Maiden 5urnama)
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<br />r Edward J. Hamrick Dorothy Rollins
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<br />13. EVER IN U.S. ARMED FORCE57 Give dates of aervlce II yes. 14s. INFORMANT•NAME 14b. RELATIONSHIP TO DECEbENT
<br /> (Yes, no, or unk.) xIo Maurice Dean Taubenheim Husband
<br />~' 16b. LICENSE N0. 18c. PATE (Mo., Day, Yr. )
<br />15. METHOD OF DISPOSITION 1Aa.EMBALMEB-SIGNATURE
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<br />Geurial ^bvnation ~t' 1339 March 17, 2UU7
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<br /> STATE
<br />CITY/TOWN
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<br />`1 ®Cremellon UEntombmenl iSd.CEMETERY EMA70pYCROTHER OCATION
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<br />~, , ^Removel ^Other(Speclfy) Central Nebraska Cremata.on Gibbon Nebraska
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<br /> 17b. Zip Cvde
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City arTown, 51ete)
<br />"''"' Horner-Lieske-Hornet Mprtuary P.D. Bax 777, Kearney, Nebraska 688413-0777
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<br />'= °' -diseases, InJurles, or complications-shat directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />1A. PART I Enter the chain oLevents-
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<br /> respiratory arrest, or ventricular librillalion without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add addltlonal Ilnes If necessary. I
<br /> IMMEDIATECAUSE~ I anset(odeath
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<br />IMMEDIATECAUSE(Flnel
<br /> dleeaeeorcondltlonreeulNng DUE T0, OR AS A CONSEDUENCE OF: I onset to death
<br /> In death) I
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<br />Sequentially Ilst condltlona, II (6) I
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<br />~~ en ,leadln toihecaueelleted ~--_---_._._. ~.....
<br />Y g bUE 70, OR AS A CONSEDUENCE OF: I onset td death
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<br />theeventareeulttnglndeath) bUE 70, OR AS A CON5EOUENCE OF: _.~"'" """'~' __ ........
<br />I onsettodeath
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<br />i 1 e, PAR711.07HER SIGNIFICANT CONDITIONS•Conditions canirlbu Ing to the death but not resulting In the underlying cause given In PAR71. 18. WAS MEDICAL EXAMINER
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<br />r1 ~ ~ ~ t.~~hY` ~ hC OR CORONER CONTAC7EDT
<br />1 ~~~.: aT. Chi t 114:se~~., i ~j~l~'~~~ ~ ~N e~01'!`~ I°
<br />^ YE5 ~ NO
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<br />20.IFFEMgLE: 21 a. MANNER OF DEATH 21 b. IF TRANSPOR7ATIONINJURY 21 c. WAS AN AUTOPSYPERFORMED7
<br />~~~ -' ~ Not pregnant within past year ^ Natural ^ Homicide Q OrlverlOparator
<br />^YE5 1~N0
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<br />^ Pregnant at Ilma of death ^ Accldenl^ Pandlpg Inveshgatlon __-..__
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<br />~~' ^ Pedestrlen
<br />^ Not pregnant, but pregnant wlthln 42 days of death 21d. WERE AUTOPSY FINDINGS AVgILA9LE TO
<br />^Suicide ^Couldnalbedetermined
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<br />~; ^ Other (Specify) COMPLETE CAUSE OF bEATH7
<br />^ Not pregnant, but pregnant 4S days Io 1 year belore death
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<br />- ^ Unknown II pregnant wlthln the past year G YES ~ NO
<br /> 22e. DATE DF INJURY (Mo., Day, Yr.) 226. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, olpce bulltling, conehuctldnelle, eta (9peelfy)
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<br />Krl 22d.INJURYATWORK? 22e.
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<br /> 221. LOCATION OF INJURY • STREET & NUMBER, APT. N0. CfTY/tOWN STAfE ZIP CODE
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<br />' 23a.0ATE OF pEATH (Mo., Day, Yr.) a 24a. DATE SIGNED (Mo., bay,Yr.) 24b.TIME pF pEATH
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<br />'~'~ Larch 12, 2007
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<br />~} 236. DATE SIG D(Mo~Day,Yr.) 23c71ME0FDEATH _~ 24c.PRONOUNCEDDEAD(Mo.,pay,Yr.) 24d.TIMEPRONDUNCEDDEAD
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<br />' 24e. On the basis of examhretlon end/or Invsatlgation, in my opinion death occurred e!
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<br />23d. To the best of my knvwled e, death occurre 'at the time, date and place
<br />d Title) r ~' C ~ the time, date and place and due to the cause(s) stated. (Signature and Title) •
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<br /> 25.DIDT08ACCOUSECONTRIBUTETOTHEpEATH? 26a.HA50.RGANORTISSUEpONATIONeEENCONSIDERED7 28b.WA3CONSENTGRANTEDT
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<br />^YES S~NO Ll PROBA84Y ^ UNKNOWN
<br />^ YES NO
<br />Not Applicable if 28a is NO ^YES ~ NO
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<br />27. NAME,7ITL~p.NDADDRES50FCERTIFI FL 1e SICIAN,COROjJ yySPHYSICIANORCOUN7 ATTORNEY) ( p orPrln,1
<br />Grand Island
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<br /> 2Aa.REGISTRAR'SSIGNATURE 1 2Ab. pATE FILED BY REGISTRAR (Mo., Day,Yr.)
<br />MAR ~ ~ 200
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