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STATE OF NEBRASKA ~ , "=w~"~~ "~ "~ ~ ~ '~
<br />tM1;HEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT DF .HFA~.7~•F;;4ND•MUMAM SERVICES; IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE~R.~KA,~~+QF~1~T~IE~FT O'F HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY ~Or7`;V71-1~'~ R~C7Rb~ +'
<br />. d'
<br />DATE OF ISSUANCE
<br />10/16/2009 2 0 0 910 2 4 5 '~~'~'41HT STATE R GI$T,RAFZ,~
<br />L~EPt~T1!'1~7' ~~fiy'~1~©.
<br />LINCOLN, NEBRASKA W,L'~MQAPw~S~ ~~- ,~W
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S~~tVlt~`~ .~ ~,I ,, ` .• Q~ Q2$~ O
<br />CERTIFICATE OF DEATH - ~ "'~ ~ -
<br />DECEDENT'S•NAME (First, Middle, Last, Suffix) Z. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />Lester Leonard Baasch Mafe October 10, 2009
<br />CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yrs.) MOS. DAYS HOURS MINS.
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<br />Aida, Nebraska 84 August 28, 1925
<br />'. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />508-26-1285 HOSPITAL ^ Inpatlant OTHER ^ Nursing Home/LTC Q Hospice Facility
<br />ib. FACILITY-NAME (If not Institution, glue street and number) ^ ERlOutpatlant ^ Decedent's Home
<br />Lebensraum ^ DOA ®Other (Spaclfy)gSSISTED LIVING
<br />tc. CITY OR TOWN OF DEATH (Include Zlp Coda) 8d. COUNTY OF DEATH
<br />d 68803 Hall
<br />Grand Islan
<br />la. RESIDENCFi•STATE 9b. COUNTY 9c. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />9d. STREET AND NUMBER e. APT. N
<br />118 S. In ails St.
<br />Itta. MARITAL STATUS AT 71ME OF DEATH ^ Married ^ Never Married 10b. NAME OF SPOUSE (First, Middle,
<br />^ Married, but separated ®W{dowed ^ Divorced ^ Unknown Aldeen Jeanette Scheel
<br />11. FATHER'S-NAME (First, Middle, Last, Suffix- 12. MOTHER'S-NAME (Firs
<br />Clarence Baasch Anna Wiese
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. 14a. INFORMANT-NAME
<br />(Yes, No, or unk.) NO Terri Ann Deaton
<br />O. 9f. ZIP CODE 9g. JNSIDE CITY LIMITS
<br />88803 ®YE5 ^ NO
<br />Last, Suffix) If wife, glue maiden name
<br />Middle, Malden Surname)
<br />15. METHOD OF DISPOSITION 18a. EMBALMER-SIGNATURE 186. LICENSE NO.
<br />® Burial ^ Donation Daniel D Naranjo 1071
<br />^ Cremation ^ Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN
<br />^ Removal ©Other (Specify)
<br />Grand Island City Cemetery Grand Island
<br />17a. FUNERAL HOMfc NAME AND MAILING ADDRESS (Street, Clty or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />B. PART I. Enter the fnaln of ayente•.dlteases, InJunet, or compllcationadhat dlrodly caused the death. DO NOT enter terminal events such as cardiad arrest,
<br />roaplrotory arrest, or ventricular fibrillation without snowing the etiplegy. DO NOT ABBREVIATE. Enter only pna cause on a Ilne. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Myocardial Infarction
<br />disease Or condition resulting
<br />In death) DUE T0, OR AS A CONSEQUENCE QF:
<br />Sequantlally Ilst condltlpna, If 4)
<br />any, leading to the cause Iletad
<br />on Iina a. DUE TO, OR A3 A CONSEQUENGE OF:
<br />Enter the UNDERLYING CAUSE ~)
<br />(diieaee or InJury that INUarod
<br />the events resulting In death) pUE TO, OR A5 A CONSEQUENCE OF:
<br />4A8T d)
<br />STATE
<br />;. PART IL OTHER SIGNIFICANT GONDITIONS•Condltlons contributlnq to the death but not resulting In the undaAying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />Dementia
<br />® YES ©NO
<br />I. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 27 c. WAS AN AUTOPSY PERFORMED?
<br />^ Not pregnant within past year ®Nalural ^ Homicide ^ DrlvatlDperalpr ^ YES ® NO
<br />^ Pregnant qt time pf death ^ AccldeM ^ Pending Inveatigatlon ^ Patuenger
<br />© Not pregnant, but pregnant within 42 days of death ^ Padaslrlen 21 d. WERE AUTOPSY FINDINGS AVAILP
<br />^ Suicide ^ Could not be datermined Tp COMPLETE CAUSE OF DEATHS
<br />^ Not pregnen6 but pregnant 4J days to 1 year before death ^ Other (Speclly)
<br />© Unknown If pregnant wkhln the peel year ^YES ^ NO
<br />2a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY Z2c. PLACE OF INJURY•At home, term, street, factory, office building, construction site, etc. (SpecHy)
<br />INJURY AT WORKT I22e. DESCRIBE HOW INJURY OCCURRED
<br />^ YES ^ NO
<br />LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITYITOWN
<br />$3a. DATE OF DEATH (Mo., Day, Yr.)
<br />W Uctober 1U, 1UUH
<br />} 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />~ z October 14, 2009 08:10 PM
<br />O SSd. Tp the best dl my knowledge, death occurred at the [Imo, date and place
<br />and duo t0 the cause(s) staled. (Signature and Title)
<br />Travis S. Hageman, MD
<br />. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS C
<br />^YES ^ NO ^ PROBABLY ® UNKNOWN [] YES
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />16c. DATE (Mo., Day, Yr.)
<br />October 14, 2D09
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />88801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Hours
<br />onset to death
<br />onset to death
<br />onset to death
<br />ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.) 244. TIME OF DEATH
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<br />~' 24c. PRONOUNCED DEAD (MO., Day, Yr.) 24d. TIME PRONOUNGED DEAD
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<br />w ~ 2M. On the balls of examination andlor investigation, in my opinion death occurratl at
<br />~+ Z ap the lime, date and plats and due to the cauiele) stated. (Signature and Title)
<br />H ~ U
<br />~ 6
<br />NO
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />. REGISTRAR'S SIGNATURE
<br />284. WAS CONSENT GRANTED?
<br />Not Appllcabla If 26a Is NO ^YES ^ NO
<br />vne or rint
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />October 14, 2009
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