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<br />M n STATE OF NEBRASISA.-OEPARTlAENT OF HEALTH
<br />~~~ ,t•IV~~Fd BUREAU Of YITAt SUTISTICS
<br />CERTIFICATE OF i~EATN FI 5., 7
<br />- DECEDENT-NAME fiRST MIDDLE UST --'SE~ DATE Of DEATH (MO., Dvy, Yr.j
<br />;. HENRY H. HOHNSTETN , A44LE 1, JULY 19 1974
<br />RACE-(e.g., WhAe, R!ocS, Amerkan ORIGIN/DESCENT(e.q.. Hoban, Me.iion, AGE-1•.r Rin~.deT UNDER 1 YEAR UNDER L DAY DATE Of RIRTM (MO., Day. Y..)
<br />Indian ~.j (S cNY' G•rman, tic.)(Spacl(T) (Yn) ~At05. DAYS' HOURS. MINS.
<br />.. U1HI7PE s. AAiE1CAN ~ `• Id. 75 bb d. ! ~T~4Ay 331, 1904
<br />CITY ANO STATE OF BIRTH (1( nol in U.S.A, CITIZEN OF WHAT COUNTRY MARtiED, NEVER MARRIED, NAME OF SPOUSE (I(edr, pi.a maiden namt7
<br />y} WIDOWED, DIVORCED!Sp•c./yl
<br />eLINCOLN NEBRASKA p. USA Ig h1ARRIED II.DUROTHY PETERS
<br />SOCIAL SECURITY NUMBER USUAL OCCUPATION(Gi.a Lindol~..orL done derinp marl TKINDOf EU51NE550R iNDU57RY COUNTY Oi DfATH
<br />~:.
<br />,g. 50b-O7-2326 ~~~SAI~SAIAN(ret~r~j t~ubPRINTTNG C IIo. DOU
<br />CITY, TOWN OR LOCATION OF DEATH INSIDE CITY LIMITS . HOSNTAL OR OTHER iNSiITUTION-Nano (ll naf in eirh.r, tf NOS( OR (HST 4daw• DOA,
<br />($Penf YtT or No) giet rtnN and nemb«/ Ovrper~•wr/Ew•r. tm.. I.rpeMnr ($prRTf
<br />„b. OMAHA ik lTES ,.d_CLARKSON HOSPITAL I,t. INPATIENT
<br />- RESIDENCE-STATE COUNTY CITY, TOWN OR IOCATIQN STREET AND NUMBER INSIDE CITY lUMTS
<br />fspeca r., or No}
<br />TSa NEBRASKA ,sb HALL I1s<.GRAND ISLAND ilsd. 323 E• S70LLEY PK. Is.SY~S
<br />iAT"~H R-NAME NRST MIDDLE UST A10TNER--MAIDEN NAME FIRST MIDDLE LMYT--
<br />~rb. JOHN HOHNSTEIN I,7 LENA GLAUTZ
<br />WAS DECEASED EVER IN U.S. ARMED FORCEST INFORMANT-NAME-RFLAIrONSHIP-MAILING ADDRESS (STtER M t~,p,pp,,~ TT O ~~,,jy f~~{[
<br />p•...w «..,:) w,.,, p,»-e. end aPr.. ar ....,<•I VKANiJI 1J[[ NU,AT NCR.
<br />`le. NO ~ Io.It1RS. DORL?THY HOHNSTEIN, UIIFE, 323 E. STOLLEY P~. ~€x¢-1
<br />BURIAI,Cnmation, pemowl OAT J~ ~1 CEMETERY OR CREMATORY-NAME IOCATiON CITY OR TOWN $tATE
<br />aoe. BURIAL mb. 1979 f ~ IaD..UIESTLAWN b4~MC7RIAL PARK (sod. GRAND IS~ANO~ NEBRASK
<br />f LMER-S NAlUR d LICENSE NO~;C j~' iUNERAI HOME-NAME ANO ADDRESS (STREET OR Rf O. No. Ott OR rowH. siAi[. zlP,
<br />z [~ ~~L+1.~-Lt~'~t~_ B(IFLER-GEI7DES, 11Y3 lV 2nd ~RANt1 ISLAND-, NE. 68801
<br />a~~l ~.a+(1 +.d~ ~_.^_ _rl-",-~1 ~ a-.d P`~a o~ .i..~ s.`.a h ~ =r I.7., Yn• SPJ. o: .i.ewen na/or uporiar~ in ,. ep~nww aw.b «a«..d .i -
<br />.~.~--~• "?T7 M ee•, der. end Plm• .wd d.• re .M .e•r(q s+ehd
<br />3 1]a. (s, ,,,. end r,p., S ~ L'e e.L.-Y.- L~~"'V-' ~ l ~ ~ ~ Zso rs.Rn.e... e,d T~d•1
<br />g~ DA r IGNED (~., Doy, Yr.} HOUR OF DEATH ~ g~C ~ Mo. oy, .. A H
<br />~_~ I E9b. 7/..1/ 79 __ 1h. ~ : SS Aht M Iii= S~Sab. 11AC M
<br />E DATE OF DEATH (Ab., Ocy. Tr.) 'a~O (PRONOUNCED DEAD PRONOUNCED DFAp(Hoarj
<br />'~ !__, 7/19/79 'o: ftMe,Dey.rr)
<br />NAME ANO ADDRESS ~ CERTIf1ER (PHYSICIAN, CO ER'S PHKICIAN OR COUNTY ATTORNEY) (Type or Ir.nN
<br />P. F. Paustian, M.D 301 Doctors Bldg., Omaha, NE 68131
<br />REGISTRAR ~f~ T~~'~----~A--~pATE RECEIVED RY REGISTRAR (Mo, Doy. Yr.j
<br />xeo.(:+Reeroq,> `If,-G7` ~ . ~ Ise. ~ u ~ 2 71979
<br />Z7. (MME AT RUSE (ENTFt ONLY ONE CAUSE PfR LINE TOR (o), (b), AND (r)) •hnol ba.e•e •nw eed deerh
<br />Pi"TPncumonia with congestive heart failure _ _____ 4 weeks
<br />(.r
<br />6L1E , OR A$ A t SEQUENCE Of: }Iwr.rwl b•r.e•• e•rr .•d d•eM
<br />i~#zigir jiui,lEVlLi'€l,T -rrfar:,t 4 weeks
<br />DuE [{~, tHL A$ A tONSEP>aUENCE OF= ~ *.nai GmaR+ •=re •nd dw~
<br />Colonic pseudo obstruction o£ unknown etiolo '
<br />Is+ gY ~~ 8 weeks
<br />PAR+~N AN•ndaeao, rUee.b.tbR b dwlh 0r~ ,a :•lawd i 1i re U tEtrtt€ W M€tS • : ~Li1L>a3e _-.. ?V!3j fd-EE !'fERR_.L+ if<+~..~A€
<br />FONAN[T IM €fE AST SS€4titfHl {SP•:Je Yu a NeJ €xAalln;t pR tpRQM;R
<br />G~'anulomatous ilea-colitis, [}ost-o stat4js ~ LSP•<dTT««N°'
<br />i a..Ta t~nn- L. ; ..1 -_ _ 1} i YeY it H a ~7R VPS ~79 _
<br />~~.~~EZi(£."~kAG'3T•.'. 5>,RxRE HO'r .wYiY .iC2Y~E4
<br />- MPEId01H0 INVESFIGATION (Sp«~ttl ~ I
<br />O;;URT AI W - PLACi 4T I~HvGY k. two {v.r. v.•at. fc.nry.
<br />(Sp«AY Tr er N•y -i 6 ~rd~wp •x !ip•r iY! II~fAP%1H ~~ ETRFFT Of R€_0 FM EtR gt YOY/M- fFAT1 -
<br />70.. SDI II 10p ~___--___ ._
<br />W88Et7~'"t"HISg~Y CARRIES THE RAISED SERL OF THE NEBRASKA
<br />~5.~'~"$IE,°~~P.AR~ENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br />~r `fR11E•~~Y - AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />PAxI~~3t~~~T~"~lEALTH, BUREAU OF VITAL STATISTICS, WHICH
<br />I',~=~~H~,!L G ~,DTwPOSiTORY FOR VITAL RECORDS.
<br />~'- ;',~, •....«{ ~,_\. ;~ ~J Jf n /tea: R a ± ~
<br />DIR.P~'" EPITAL STA
<br />~~~-.r TISTICS AN;3 ASSISTAN% -STATE REGYSTRAR
<br />LINCOLN, NEBRASKA Issued August 6, 1979
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