|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH .xINQ I=lI,~MA'N SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR6tSK.9'~~,~t1`~L~l1kT,iOF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY Fpf~ V,i7"A~;;REICC7~DS
<br />DATE OF ISSUANCE ~~~~~ ~~'
<br />04/12!2010 StANLi~Y S. COOPER
<br />2 Q~ ~ O~ O 5~ ,QSSIS.`l"ANT,STATE REG757RA1~ .'
<br />DEP`A, I~TM~tT OF HEALTJ-I ANf~ , `:
<br />LINCOLN, NEBRASKA Ht/I~61N SERVICES
<br />vp. .
<br />STATE OF NE9RASKA • DEPARTMENT OF HEALTH AND HUMAN SER~IGt;~ ~.'~ ~ 10,00937
<br />CERTIFICATE OF DEATH • `'" ~~ ~' •:~•i w
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX '_ ~ ;
<br />~ 3, DATE pF DEATH ~Mo., Day, Yr.)
<br /> Lego Garland Hauptmeier Male
<br />`` W ~ , . 'April 1, 2010
<br /> 4. CITY ANp STATE OR TERRITORY, OR FOREIGN COUNTRY OF F31RTH 5a. AGE • Last 8lrthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. BATE OF BIRTM (Mo., Day, Yr.)
<br /> (Yn•I MOS. DAYS HOURS MINE.
<br /> Tecumseh, Nebraska 65 August 11, 1944
<br /> 7. SOCIAL SEGURnY NUMBER 8a. PLAGE OF DEATH
<br /> 507-56-4449 HOSPITAL ®Inpatient OTHER ^ Nursing Nome/LTC ^ Hospice Facility
<br /> 8b. FACILITY-NAME (If not Instltutlon, gh!e street and number) ^ ER/OutpatleM ^ DecedenCs Noma
<br />a
<br />~
<br />V
<br />Saint Francis Medical Center
<br />^ Doa ^ Other(SpecHy)
<br /> 8c. CRY OR TOWN OF DEATH (Include Zlp Code) 8d. COUNTY OF DEATH
<br />iS Grand Island 68803 Hall
<br /> 9a. RESIDENCE•STATE 96. COUNTY 9c. CITY OR TOWN
<br />w
<br />z Nebraska Hall Grand Island
<br />~ ed. STREET AND NUMBER 9e. APT. NO. 9F.21P CQDE 9g. INSIDE CITY LIMITS
<br />~, 1423 North Walnut Street 68801 ®YES ^ Na
<br />~ 10a. MARITAL STATUS AT TIME pF DEATH ^ Married ^ Navar Married 706. NAME pF SPOUSE (Flr;t, Middle, Last, Suffix) H wife, Alva maiden name
<br /> [] Married
<br />put separated ^ Widowed ®Dlvorced ^ Unknown
<br />m ,
<br /> 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S•NAME (First, Middle, Malden Surname)
<br />~ Henry Hauptmeier Eva Sachs
<br />a
<br />E 13. EVER IN U.S. ARMEp FORCES? Glve dates of service IT Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ (Yea, Np, or unk.) Yes 08/31 /1965-08/30/1967 April Labedz Daughter
<br /> 15. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 18b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />H ®8urlal ^ Donation
<br />Daniel D Naranjo
<br />1071
<br />April 7
<br />2010
<br /> ,
<br /> ^ Cremation ^ Entombment
<br /> 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> ^ Removal ^ Other (Specify)
<br /> St. John's Lutheran Cemetery Sterling Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> AU E D A H ee nstruc ohs an exam es
<br /> 1B. PART I. Enter the ~pl~•diseaeas, InJunee, or compllcatlpns~hat directly caused the death. 00 NOT enter terminal events such as cardiac arrest, :APPROXIMATE INTERVAL
<br /> retpirdtory Afl'en, pr veMHCUIer flbrllletlOn wlthpUt ihDWlnp MB etiOlopy, b0 NOT A88REVIATE. Enter poly one coast on a Ilna. Add additional Ilnrs If na4wrrary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEp1ATE CAUSE (Final al Respiratory Failure 1 Week
<br /> alaeaaa of condition resulting -
<br /> In death) DUE TO, OR AS A CONSEQUENCE OF: :Onset to death
<br /> saquantlally Iln condnlpna, Ir b) Metastatic Esophageal Cancer 1 - 2 Years
<br /> any, leading to the cause Ilatsd
<br /> pn Ilna a.
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNpERLY1NG CAUSE C)
<br /> (dlseaae pr InJury that Inltlnad
<br /> the events reauhlnp In death) DUE TO, OR As A CONSEQUENCE OF: . pn;et to death
<br /> LAST d)
<br /> 18. PART II. pTHER SIGNIFIGANT GDNDITIONS•Condltlons contributing tp the death but not resulting In the underlying cause given in PART 1. 79. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> ^ YE8 ®Np
<br />
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21 b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />~ ©Hot pregnant whom past rear ®Natural ^ Nomiclaa ^ Onvadpprretor
<br /> ^YES ®NO
<br />W Prepnam et time oT death
<br />^ Acpldent ^ Pendipp Invenipatlpn ^ Paawnpar
<br />~ ^ Not pregnant, but pregnant within 42 dayr of death
<br />^ 5uicltla ^ Could not ba determined ©Padenrlan 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />
<br />^ Not propnant, but pregnant 43 days l0 1 year tMfpro death
<br />^ Other (SpeclTy) Tp GDMPLETE CAUSE OF DEATH?
<br /> ~'] Unknown iT prapnam within the pan year [] YES ^ NO
<br />a
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, office building, cpnstructlon site, etc. (Specfy)
<br />
<br />~i' 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />O
<br />~
<br />^YES ^ NO
<br /> R2f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CRY/TOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.) ~_ - ~ 24a~DATE SIGNED (Mo., Da , Yr.)
<br />_: Y 24b. TIME OF DEATH
<br />~_._....v,~.:.. ...
<br /> ~' W April i, 2010 ~o
<br /> ~ 23b. DATE SIGNED (Mo., Da , Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (MO., Day, Yr.)
<br />~ ~ 24d. TIME PRONOUNCED pEAp
<br /> ~vi x115,2010 10:OOPM r
<br />~a6=
<br /> C Sd
<br />Tp [ha 4eat of my knowledge
<br />death occurred at the time
<br />data and place ~ ~ O
<br />
<br />~ .
<br />,
<br />, w 24a. On the bawls pf examinatlpn and/or Invastl9stlon, In my opinion death occurrod at
<br /> o and due tp [ha pause(s) stated. (Signature and TItk) o ~ ~ tna time, data and place and due to the cause(s) Hated. (8lpnature antl 7kIa)
<br /> ~ : DDUglas Herbek, MD '" ~ ;
<br /> 25. DID TOBACCO USE CONTRIBUTE TO TWE DEATHS 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERE07 28b. WAS CONSENT GRANTEO9
<br /> ^ YES ^ ND ^ PROBABLY ® UNKNOWN ^YES ®NO Not Applicable H 28a Is NO ^YES ^ NO
<br /> 2 L 1 A R pe pr tint)
<br /> Douglas Herbek, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 286. DATE FILED 8Y REGISTRAR (Mo., Day, Yr.)
<br /> April 7, 2010
<br />
|