|
STATE OF NEBRASKA " .p
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH.,•A"l'dL'ri'~(II~,4iM~S~ERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA 4dF~R~h~~NT p4F, HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPpSITpRY FpR .IYIz'AL~T:l~ECQRDS.. ,
<br />, ; i"~ r' .
<br />DATE OF ISSUANCE ~ ~ ; f , ~'~ ,;'
<br />c o s zoto 2 010 0 2 1 4 3 ~~~~~'~ ~~ao~ER ; ~:
<br />A',$S~~"AN~.S~AT& REGISTRAfi" °, .
<br />D~P~R~"M NT QF HEALTH iAlVp ,
<br />LINCOLN, NEBRASKA HUMAN SE62VTEE5 r ' ~ "
<br />~ 7..
<br />,N rw,
<br />I ~,, ~ ,~
<br />STATE QF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICE
<br />Amended Februar 5 2 10 ~ ~ ~ ~~
<br /> 1. DECEDENT'S-NAME (Pint, Middle, Last, Suffix) 2. SEX ~a:.4ATE bF pEATTFIMo.,Dtry,Yt:)
<br /> William Allan Lechner Male Janua 24, 2010:
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY pF BIRTH sa. AGE-Lx! Blrlhdry 66, UNDER 1 YEAR lk, UNDER 1 DAY ~, pATE..~plit?H (Mo., Day, Yr.)
<br />~~
<br /> (Yrr.) MOS. OAYB wourta MB~a September 28
<br />, 1951
<br /> Grand Island, Nebraska 58 ~2S-4Ar~
<br /> Y. SOCIAL SECURITY NUMBER 8a PLACE OF DEATH
<br /> 506-66-5001 HOSPITAL: ©Inpatlem 4i!lEg: ^ Nuninq HomdLTC [~ N°.plu Facility
<br /> 86. FACILITY-NAME (H net Inatltution, give stroat and number) ^ ER/Ou~atlatt ®DacadenNs Moma
<br /> 3495 N. Burwick Road ^ pon ^bthegsp.°Iry)
<br /> 8c. CITY OR TOWN OF DEATH pncluda Zlp Code) Bd. COUNTY OF DEATH
<br />' Cairo 68824 Hall
<br /> sa. RESIDENCE-STATE sb, COUNTY 8C. CITY OR TOWN
<br />~, Nebraska Hall Cairo
<br />a
<br />& 9d. STREET ANp NUMBER se. APT. Np. 9f. YIP CODE eg, INSIdE CITY LIMn'S
<br />LC 3495 N. Burwick Rgad 88824 ^ Yea ®No
<br />~
<br /> 10a. MARITAL 8TATU$ AT TIME pF DEATH ®Marred ^ Never Married 1lib. NAME OF SPOUSE (Pint, Middle, Last, Suffix) H wNe, give maiden mrnr.
<br /> © Herded, but repareted ^ Widowed ^ Divorced ^ Unknown Maril n Berstler
<br />E
<br /> 11. FATHER'S-NAME (Pint, Middle, Last, Sumx) 12. MpTHER'8-NAME (First, Middle, Malden Sumams)
<br />~ Tedd Lechner Imo ene Neumann
<br />m 1a, EVER IN U.S. ARMED FORCES? Glve dates vT setWce if Yes. 14a INFORMANT-NAME 146. RELATIONSHIP TO DECEDENT
<br />F
<br />(Yes, No, or Unk.) Np
<br />Maril n Lechner
<br />Wife
<br /> 18. METHOD OF DISPOSITION 78a. EM MER•81GNAT~{RE"'~ 186. LICENSE NO. 78c. DATE (Mo., Day, Yr,)
<br /> ^B"del ®°°eeti°" ~
<br />LV1 ._.t I ~ ct 7 Janua 28, 2010
<br /> ~cndlulen ©entanbmrnt
<br /> ^Ranouel ^tNhrr(SgcNy) tad. C METERY, CREMATORY OR OTHER LOC TION CITY/TOWN BTATE
<br /> Nebraska Anatomical Board, Omaha Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 1Tb.21p Coda
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 88801
<br /> CAUSE OF DEATH See instructions and exam les
<br /> ts. PART 1. [mar tn. cmin o/ ewrds _ dhe.ree, Inludn, or complM.anenr-mat mnetty csvrrd tIN tlenn. Do Noy rrnrr termimuwmx weh a, cerdNc err„t. ,APPROXIMATE INTERVAL
<br /> re.plntury erml, °r wnMeulrr Rbdlleaen wlmwd eb°wlnB tM reoloey. D° NOT ABBREVIATE. EMrr only an. N°N en a Iim. Add eddraoxal IIM. d MCNfary. r
<br /> IMMEDIATE CAUBE: ' ensat tv death
<br /> IMMEDIATE CAUSE (Final r
<br />i
<br /> diseera er eonditlon nsuldnq a)
<br />I ~ l°CL~c
<br />/'
<br />
<br />,
<br />In death)
<br /> DUE TO, OR AS A CONSEOUENCE OF: ~ onset to death
<br /> Sequentlally Ile! conditions, If b) I
<br />~
<br /> any, leading to the cause Meted
<br /> °° Iina a. DUE TO, OR AS A CONSEQUENCE OF: ~ onset t° death
<br />1
<br /> Enter the UNDERLYING CAUSE c) I
<br /> (disease orinjurythatinitlatad ~
<br /> the swntr resulUnp In death) DUE Tp, pR AS A CONSEQUENCE OF: I onset to death
<br /> LABT ~
<br /> I
<br />d) I
<br /> 18. PART II. pTNER SIRNIFICANT CpNDmpNB-Condltlnns ennMbWng m the death but noc reaulting M the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> (~ ~ ~(//}~ ~
<br />~~~ '. ~Q{f./,t:~ ~il.u[~tA-~~ OR CORONER CpNTACTEp7
<br />Q 'YES NO
<br />~ .~
<br />... ._ _....._....u= _
<br />~` FEMALE: 2
<br />1
<br />~. MANNER OF pEATN 27 b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> ^Not pregnant within past year ,vv~~
<br />,,,
<br />111
<br />~Neturel ^ Mnmidde ^ Driver/Operator ^ YES O
<br /> ^ Pregnant n ems of death ^ Accident ^ PelWlnq Investlgedon ^ parpnger
<br />~
<br />^Not prepnanL but pregnant within 42 days of death
<br />^ Suicide ^ Could net bs determined
<br />^ PederMan 21d, WERH AUTOP Y FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br /> ONotpregnant;butprsgnant43 dayato 1 yeart»rore death Q pthar(Specity) ^ YE8 ~Ib
<br /> ^Unknown it pregnant wltMn the part year ,Y
<br />m
<br /> 22a. DATE OF INJURY (Mo., Day, Yr.) 224. TIME OF INJURY 22c. PLACE OF INJURY"At home, farm, street, Tatvry, oftlce building, t:onatructlon site, etc. (Specify)
<br />U
<br />hf m
<br />
<br />0 22d. INJURY AT WORK? 22e. DESCRIBE HpW INJURY pCCURRED
<br />~ ^ YES ^ NO
<br /> 22f. LOCATION qF INJURY -STREET 8. NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br /> 2aa. DATE OF pP1ITH (Mo., Day, Yr.)
<br />w 2 24a. PATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />~
<br /> ~'
<br />January 24, 2010 -
<br />~
<br />a
<br />
<br />LL ~
<br />,
<br />m
<br />~
<br />O
<br /> ~ 2a6. DATE SIGNED (Me., Day, Ya) Rac. TIME OF DEATH
<br />~~~ ~ 25, 2010 /Z~Y7
<br />m 24c. pRONgUNCEp pEAD (Mo., Day, Yq) 24d. TIME PRONOUNCED DEAD
<br />~~~~
<br />z
<br />
<br />° V O g vl
<br />m
<br />~ ~ ? p
<br /> tad. T° the et oT my knowledge, death occurred at the time, date and place
<br />an to
<br />e cau
<br />t
<br />h
<br />(s) rated. (Signature and Tltla) 24e. On the bawls of examinatlon and/or Imestlgatlen, In my opinion death occurred
<br />$ ~
<br />at the time
<br />date and place and due to the causa(e) stated (Signatun and 71t1r)
<br /> W
<br />(I
<br />~
<br />~
<br />~
<br />~ ~ W`" V`~ ~
<br />,
<br />~ ~ U
<br />U
<br /> O
<br /> 28. DID C USE CONTRIBUTE T E DEATH? 28a. HAS pRGAN pR T188U NATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br /> ^ 0 ^ PROBABLY ^ UNKNOWN ^ YES NO Nnt Applicable tl 2sa Ir Np ^ YES ~NO
<br /> 27. NAME, LE AND ADDRESS pF CERTIFIER (PHYSICIAN, PHYSICIAN A8818TANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type yr Prm)
<br /> John A Wagoner M.n. Sp0 Alpha Street Grand Island N)~ 58803
<br /> 28e. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> ,~aN 2 ~ 2a~o
<br />
<br />
|