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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ,~IVD k,~l,~l-1,q,N SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILF WITH THE NEBRASK,4b~~ART{yE~IN'a~C7~' HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAl~w6tE~CC71~L :~ `
<br />DATE OF ISSUANCE t~~
<br />i~/~
<br />2 010 0 2 5 9 9 ~TA~~~ ~.
<br />04/05/2010 ASS~~1"R~ ~ ~1SFRA,F2 ';
<br />DEPARI'M AND'
<br />LINCOLN, NEBRASKA HUA0,41~ S~'~'
<br />STATE QF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVIC>`S '• ~/~`~~,i r r,,•• ~K'".•^` y. r' ~ Q 00~~8
<br />CERTIFIC,4TE OF 1']FATH ~ ..
<br /> L DECEDENT'S-NAME (First, Middle, Last, SuHlx) 2. SEX ,. ~ i 3. gATE,OF DEATH (Mo., Day, Yr.)
<br /> Lester Harve Badberg Male ~ March 12, 2010
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER t YEAR Sc. UNDER 1 DAY 9. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yfe~) MOS. DAYS HOURS MINS.
<br /> Talmage, Nebraska 81 May 4, 1928
<br /> 7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br /> 506-34-2340 H P ^ Inpatient THE [~ Nuraing HomeILTC ^ Hospice Facility
<br /> 8b. FACILnY-NAME (H not Instltutlon, give street and number) ^ ERlDutpatlpnt ®Decedent's Home
<br />
<br /> 6700 Platte River Drive ^ DDA ^ Other (Speclty)
<br />~ Se. CITY OR TOWN OF DEATH (Include Zlp Gade) 8d. COUNTY OF DEATH
<br />o DOnlphan 68832 Hall
<br /> 9a. RESIDENCESTATE 96. COUNTY 9c. CITY OR TOWN
<br />z Nebraska Hall Doniphan
<br />LL 9d. STREET AND NUMBER e. APT. Np. 9F. ZIP CODE 9g. INSIDE CITY LIMITS
<br />~, 6700 Platte River Drive 68832 ^YES ®No
<br />~
<br />at 10a. MARITAL STATUS AT TIME OF DEATH ®Married ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) IF wHe, gNe maiden name
<br />
<br />m ^ Married, but separated ^ Widowed ^ Divorced ^ Unknown Marseille Bergmann
<br /> 11. FATHER'S-NAME (Flret, Middle, Last, Sufrlx) 12. MOTHER'S•NAME (First, Middle, Malden Surname)
<br /> John Badberg Minnie Broeking
<br />a
<br />E 1S. EVER IN U.S. ARMED FORCES? Glva dates of service H Yes. 14a. INFORMANT•NAME 144. RELATIONSHIP TO DECEDENT
<br />s (Yea, No, or Unk.) Np Rodne Badber SDn
<br /> 18. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />H ^ Burial ^ Donation
<br />Not Embalmed
<br />March 13
<br />2010
<br /> ® C
<br />i
<br />^ ,
<br /> remat
<br />on
<br />Entombment
<br />^ Removal ^ Other (Spaclty) 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> Central Nebraska Cremation Services Gibbon Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, State) 174. Zip Code
<br /> Curran Funeral Chapel, 3005 S. Locust St„ Grand Island, Nebraska 68801
<br /> U E F ee instruct ons and exam es
<br /> fa. PART L Enter the r~tn orevr~da--disaaasa, lnjurlea, or compflcauona-that diroaly cauwd the death. p0 NOT emir arminal avanta such as carcliac arrant, ; APPRDXIMATt: INTERVAL
<br /> reaplretory arron, OY wnMcular flbdllatidn Wflhout ahowing [hp etiology. DO NOT ABBREVIATE. Elmer Onty ens cause On a Ilea. Add etlditlonal IIna9 Ir nsceswry.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final a)Ditficulty Breathing ;Immediate
<br /> diwaw or condition resulting
<br /> In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Saquenflaly list conefllena, a b) Asthma :Years
<br /> arry,leading to the puw Ilsred
<br /> on nne a.
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE C)
<br /> (tllwaw or Injury that Initiated
<br /> the evanta reauting In death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />LAST
<br /> d)
<br /> 78. PART IL OTHER SIGNIFICANT COND1710N3•Condltiona comributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br />w ®YES ^ NO
<br />~
<br />F 29. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21 c. WAS AN AUTOPSY PERFORMED?
<br />^ Not pregnant within pant year ®Na[ural ~ Homicide ^ DrlvaflOperetor
<br />~ ^ Pregnant at time of death ~ Accident ^ pending InwatlgatlOn ^ Paaaanger © YES ® NO
<br />
<br />$'' ^ Not prognan[, but pregnant within 4Y days or death ©PedasMan 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />^ Sulcida ^ Could not De determined
<br />
<br />-O TO COMPLETE GAUSS OF DEATHS
<br />^ Nat pregnant, but pregnant 43 days to 7 year beroro death ^ Omar (Specify)
<br />~ ^ Unknown If pregnant wdhin the past year ^ YE$ ^ NO
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 224. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site
<br />etc. (Specify)
<br /> ,
<br />
<br />.~ 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />~
<br />^YES [~ NO
<br /> 22f. LOCATION OF INJURY -STREET 8 NUMBER, APT.NO. CITYlTOWN STATE ZIP CODE
<br />
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<br />~' 30, 2010 Approx. p5:45 PM
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<br />. DATE SIG
<br />(Mo Da
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<br />23c. TIML: OF DEATH
<br />~
<br />~ OUNGERDEAD (Mo Day Yr.) 24d. TIME PRONOUNCED DEAD
<br /> y
<br />~
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<br />E ~ Z ~ ~ e ~ March 12, 2010 06:05 PM
<br /> D 21d. To the beat Of my knowledge, death occurred at the lima, daM and plew 8 »
<br />~ ~ ~ Yee. On the baala o} examinatlen and/or Inveatlgatlon, In my aplnlan dsalh occurred at
<br />3 and due to the auaeje) stated. (SlpnMure and Title) ~ ~ the tim
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<br />ug to tlw uuwla) anted. (Signature and THIe)
<br />~ ' `' ~
<br /> a Barbara Dunn, Hall Deputy County Attorney
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br /> ^ YES ^ NO ^ PROBABLY ® UNKNOWN ^YES ®NO Not Applicable If 28a Is NO ^YES ^ ND
<br /> D E 1 1 ype or r n
<br />Barbara Dunn, Hall peputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED 8Y REGISTRAR (Mo., Day, Yr.)
<br /> March 31, 2010
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