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<br /> STATE OF NEBRASKA
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH Alalp,F>'0AMN"4,RVICES, IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA^!j PgL4fifdl ~a Fi(iEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH 15 THE LEGAL DEPOSITORY FOR VITA 1I'ORDS...
<br /> .~~Ut
<br /> DATE OF ISSUANCE
<br /> JUN 2 3 2009 201000734 AS,N :EA... PER r~y
<br /> ,ASSI.~rTA/Uf!' G ,$TRAR_-,I ,
<br /> DE~4 `Th1EN( I~'~~ 9 AND "
<br /> LINCOLN, NEBRASKA - ._.......HU~°IAgYE/~I~I
<br /> STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES1 fi ! Q T: ;
<br /> DgATH
<br /> CERTIFICATE OF
<br /> 1. DECEDENTS-NAME (First, Middle, Last, Suffix) 2. SEX ~DATEf H',(Ma;Oay~Yr)'
<br /> Luther Fredrick Peters Male June 4; 2009'°"°
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 8a. AGE-Last Birthday 6b. UNDER 1 YEAR Sc. UNDER 1 DAY s. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MD3. DAYS HOURS MINS.
<br /> Bloomfield, Nebraska 79 October 25, 1929
<br /> 7. SOCIAL SECURITY NUMBER Be. PLACE OF DEATH
<br /> 507-26-8091 HOSP T ' [I Inpatient OTHER: ® Nursing Homa[LTC ❑ Hospice Facility
<br /> ab. FACILITY-NAMG (if not Institution, give 0treat and number) ❑ ER/Outpatient ❑ Decedenrs Home
<br /> Madonna Rehabilitation Hospital LTC © DOA [f otller(Specify)
<br /> Sc. CITY OR TOWN OF DEATH (Include 7Jp Code) 8d. COUNTY OF DEATH
<br /> Lincoln 68506 Lancaster
<br /> Sa. RESIDENCE-STATE eb. COUNTY Sc. CITY OR TOWN
<br /> 7
<br /> U. Nebraska Hall Wood River
<br /> ed. STREET AND NUMBER ft. APT. No. W. ZIP CODs= eg. INSIDE CITY LIMITS
<br /> 1312 Main St. 68883 g] Yea ❑ No
<br /> 100. MARITAL STATUS AT TIME OF DEATH ® Married Q Never Married lob. NAME DF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br /> ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown LaVOnne Frevert
<br /> 11. FATHER'S-NAME= (First, Middle, Lae; Suffix) 12. MOTHER'"AME (First, Middle, Malden Surname)
<br /> v Herman Peters Emilie Re ennin
<br /> GI 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yea. 14a. INFORMANT.NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (Yes, No, or unit.) Yes 08/0311951-07/23/1953 LaVonne Peters Wife
<br /> 15. METHOD OF DISPOSITION 16a, EMBALMER-SIGNATURE 16b. LICENSE NO. 1Sc. DATE (Mo., Day, Yr.)
<br /> ®e,m.l Qoanellan ~~~o~ap r~ ~~~"~L June 9, 2009
<br /> []Cremedon ❑6M.mbm.m
<br /> ❑ Removal []OthertliPeaNfl 1Sd. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br /> Wood River Cemetery Wood River Nebraska
<br /> 17o, FUNERAL HOME NAME AND MAILING ADDRESS (Street, Cityor Town, State) 17b. Zip Code
<br /> Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br /> CAUSE OF DEATH See instructions and examples)
<br /> 14L PART L 8mer the cheat d evert.- dl.eat.s, inlurles, or Complications- that dYeally Caused the death. 00 NOT order wradnd edema awft .e Card" wrest ! APPROXIMATE INTERVAL
<br /> r.epk.rwy r -mft dr eErtllelMn without shaedne the .tloloay. 00 NOT ASeRaxwTIL Otter arty one Cewe on a Ww. Add Cddwwl Ws-. irn•....ay-
<br /> IMMEDIATE CAUSE: ! onset to death
<br /> IMMEDIATE CAUSE (Final
<br /> disease or condition resulting a)
<br /> 1/ ! ( 1 n
<br /> hh`--~~~'"
<br /> In death) l'o
<br /> Due T0, OR AS A CONSEQUENCE OF: I onset to death
<br /> Sequendany list condidons, If b)
<br /> any, leading to the cause listed
<br /> an line a. DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br /> i
<br /> Enter the UNDERLYING CAUSE c) '
<br /> (disease or Injury that Initiate
<br /> the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br /> LAST I
<br /> d)
<br /> 18. PART It. OTHER SIGNIFICANT CONDITIONS-Condttlons contributing to the death but not resulting In the underlying cause given in PART 1. 18. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> ❑ YES R NO
<br /> 19 20. IF FEMALE: 21 e. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> 19
<br /> U. []Not pregnant within past year Natural ❑ Homicide Q DNvarlOperator YES 0 NO
<br /> ❑ Pregnaltt at time of death ❑ Accident ❑ Pending Investigation ❑ Passenger
<br /> W
<br /> 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br /> C C] Not pregnant, but pregnant within 42 days of death ❑ Suicide ❑ Could not be determined ❑ Pedestrian TO COMPLETE CAUSE OF DEATH?
<br /> aI'' ❑ Not pregnant, but pregnant 43 days to 1 year before death [a other (Specify) YES L] NO
<br /> gj []Unknown ifpregnant within the pastyear
<br /> 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, office building, consfructlan site, aft- IS pacify)
<br /> m
<br /> lu
<br /> 22d, INJURY AT WORK? 220. DESCRIBE HOW INJURY OCCURRED
<br /> F
<br /> ❑ YES ❑ NO
<br /> 22f. LOCATION OF INJURY • STREET fit NUMBER, APT. NO. CITY/TOWN STATE 410 CODE
<br /> x 23a. DATE OF DEATH (Mo., Day, Yr.) Z 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> A June 4 2009 tgr m
<br /> 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 'z Q 24C. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> ~0 1 Q, 20Q9 9:35 p m E yf 4 O ITI
<br /> 23d. To the best of my knowledge, death occurred at the time, date and place u 24a. On the basis of examination andfor Invastigation. In my opinion death occurred
<br /> and d ug ted. (Signature and Title) 2 O at the time, date and place and due to the cause(s) stated. (Signature and Title)
<br /> 01 / `/0 w 8 o
<br /> 26. DID TOBACCO USE GONTRITHE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br /> ❑ YES NO ❑ PROBABLY I,] UNKNOWN ❑ YES Ik NO Not Applicable if 2sa Is NO ❑ YES 'ONO
<br /> 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br /> Dr. Daniel Eins hr 3901 Pine Lake Rd Suite 220 Lincoln NE 68516
<br /> 28a. REGI$? SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> . JUN 17 '2009
<br /> e
<br /> "All
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