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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF MEALTH.A°1VCJ ~ICiIIA~ ERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR,~tC~ Qw~PAI~TAq~N,~t'~ HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR"1s'I~sraP REC S. ". )
<br />DATE OF ISSUANCE
<br />08/26/2009 2 Q 10 018 2 3 ; .a,~sl~srANS~~+T~"~R~ISrR~+R :•~
<br />~~> t~P~,R•TM T O~ ~A '7!H ANp ;a
<br />LINCOLN, NEBRASKA j~ H('M~ • SERVICES ~ ~,
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN $ERVI~E9;• ' • ,~ f1 j ~ ~"y','> •" ~ '!` x..09 01$57
<br />CERTIFICATE OF DEATH " t , '}'I` ~,' ' ' ' • "' , , ;' .M,
<br /> 1. pECEDENT'S•NAME (First, Middle, Last, Suffix) 2. SEX ~ „ 3:~ATE OF DEATH (Mo., Day, Yr.)
<br /> Jo ce Minnie Harder Femals '•Atigiis414, 2009
<br /> 4. CITY AND STATE OR TERRITORY, pR FOREIGN COUNTRY pF BIRTH 5a. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY B. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br /> Boelus, Nebraska 88 December 7, 1920
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 505-7&7618 H PITAL ®Inpatlent OTHER ^ Nursing HomelLTC ^ Hospice Facility
<br /> 8b. FACILfTY•NAME (If not In;tltutlpn, glue Street and number) ^ ERlOutpatlent ^ Decedent's Hpme
<br />
<br /> Howard County Community Hospital ^ Dan ^ Other (Specify)
<br />w
<br />K 8c. CITY OR TOWN OF DEATH (Include Zlp Coda) 8d. COUNTY OF pEATH
<br />a 5t. Paul 68873 Howard
<br />a 9a. RESIDBNCB•STATE 9b. COUNTY 9c. GITY OR TOWN
<br />W
<br />z Nebraska Wpward Boelus
<br />LL 9d. STREET AND NUMBER e. APT. NO. 9f, ZIP CODE 9g. INSIDE CITY LIMITS
<br />~, 2026 H 58 fi882D ^ YES ®No
<br />
<br />.$ 1tla. MARITAL STATUS AT TIME OF DEATH ^ Married ^ Never Marled lob. NAME OF SPOUSE (First, Middle, Last, Suttlx-1(wNe, glue maiden name
<br /> ^ Married, but Separated ®Widowed ^ Divorced ^ Unknown
<br /> 11. FATHER'S•NAME (First, Meddle, Last, Suffix) 12. MbTHER'S-NAME (First, Middle, Idelt umams)
<br /> George Jess Frieda Lemburg
<br />
<br />~
<br /> 13, EVER IN U.S. ARMED FORCES? Give dates of service H Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TD DEGEDEN7
<br /> (Yea, No, or unk.) No Diann Muhlbach Daughter
<br /> 15. METWOD OF DISPOSITION 18a. EMBALMER-SIGNATURE 18b. uCENSE NO. 18c. PATE (Mo., Day, Yr.)
<br />F ®eurial ^ Donation Timeree Andreasen 1390 Au
<br />ust 20
<br />2009
<br /> g
<br />,
<br /> ^ Cremation ^ Entombment
<br />
<br />^ Removal ^ Other (Specify) 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY! TOWN STATE
<br /> Grand Island City Cemetery Grand Island Nebraska
<br /> 77a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Glty or Town, State) 176. Zlp Code
<br /> Jacobsen-Greenway Funeral Home, 411 O Street, PO Box 112, St. Paul, Nebraska 68873
<br /> AU E F DEATH ee nstruc ors an exam es
<br /> 16. PART I. Enter the chain of events--diseases, Injudas, or compllcatlonadhat dlnctly caused the death. DO NpT enter tarlnlnal events such as cardiac arreal, APPROXIMATE INTERVAL
<br /> rosplro[ory arrest, or ven[rlcuiar gbrlllatlon without showing the etiology. DO NOT ABBREVIATE. Enter only Ane cause on a Ilse, AAA additional Ilnea I} neceswry.
<br /> IMMEDIATE GAUSE: Onset t0 death
<br /> IMMEDIATE CAUSE (Find! a) Respiratory Failure 7 Days
<br /> disease or condition nauklnq
<br /> In death) pUE Tp, OR AS A CONSEQUENCE OF: onset to death
<br /> Saquenually Ilet condlllone, If b) Congestive Heart Failure
<br /> any, leading to th0 cause IltteA
<br /> on Ilna a.
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE C)
<br /> (disease or Injury that Initiated
<br /> the events roaultinp In death) DUE TO, OR AS A CONSEQUENCE OF: 7 onset to death
<br /> LAST d)
<br /> 18. PART IL OTHER SIGNIFICANT CONpITION3•Gondltlons contributing to the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> Chronic Obstructive Pulmonary Disease OR CORONER CONTACTED?
<br /> ^ YES ®NO
<br />~
<br />W 20. IF FEMALE: 21 a. MANNER OF DEATH 21 b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br /> ^ Nvt pregnant whhln past year ®Naturel ©Homiclda ^ Drlvadpparelor ^ YE$ ® NO
<br />~ ^ Pregnant at time of death ^ AcrJdent ^ pending Inveslipation ^ Passenger
<br /> © Not pregnant but pregnant wlthln 4Z days aT death Suicide Could not M derermined
<br />^ ^ ^ Pedaa[dan 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br /> ^ Not pregnant, nut pregnant 47 days to 1 year beroro deatn ^ Other (SpeNfy) TO COMPLETE CAUSE OF DEATH?
<br /> Unknown IT pregnant wlthln the peat year ^ YES ^ NO
<br />. 22e. PLACE OF INJURY•At home, farm, street, factory, ottka hullding, conatni~f)Qn~,iS9, etc. (Spgclf~)~ __
<br />s
<br /> 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />ti
<br />^ YES ^ NO
<br /> 22f. LOCATION OF INJURY • STREET 8, NUMBER, APT,NO. CITY(TOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mp., Day, Yr.) ~ 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> ~ ~ August 14, 2009 ~
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<br /> 13 r 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ~ v' ~ 24a. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNGED DEAD
<br /> rs ~ Au ust 24, 2009 10:30 PM ~
<br />$¢ ~ ~
<br /> e ~ aA. Tc the beat of my knowledge
<br />death occurred at the term
<br />date and place ~+ ~
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<br />`' the time, date and place and due to the teasels) stated. (Signature and Title)
<br /> Chris Tomhave, MD g
<br /> 25. DID TOBACCO USE GONTRIBUTE TO THE pEATH9 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED9
<br /> ^ YES ^ NO ^ PROBABLY ® UNKNOWN ^ YES ®Nq Not Applicable K 28a Is NO ^ YES ^ NO
<br /> A F I I Y A N 1 ype or r nt
<br /> Chris Tomhave, MD, 1122 Kendall St., P.e. Box 405, 5t. Paul, Nebraska, 68873
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> August 26, 2009
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