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STATE OF NEBRASKA
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<br />WHEN THIS CDPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT DF HEALTH.HU1N'A1IlI SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINRL RECORD ON FILE WITH THE NEBRA5f4.~fi~p,~PAVdTM, ~IVT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR •VIT~4L~IQ~COR~a~.~,"`
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<br />PATE pF ISSUANCE ~ ~C.A ~~ ~
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<br />~u~ o~ za~U 2 0 1 0 0 4 8 0 9 A'~~~~A ~r ~r~ ~ ~~~~S~RA~~ ,,
<br />DEPxIRTM~IVr dF HE~tr57H AND
<br />LINCOLN, NEBRASKA _. _ - HLIN~giN'•SERVICES ;'^`
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<br />&TATE OF NEBFtASKA-DEPARTMENT C)P HEALTH AND HUMAN SERVICES FINANCE AND $UPP~t~ ~'e~ ~ ~ yG .~
<br />C~RTlF1CAT~ QF DE=ATM u c.+ U
<br /> 1. DECEDENT'S-NAME (Flnl, Nltltlu, Last, SullixJ 2.$EX 7.OATEOFDEATH(MO..Day,YGl
<br /> Lorraine NMl Luebbe Female August 11, 2008
<br /> .a. CITY AND STATE OR TERRITOflY, OR FOREIGN COUNTRY OF BIATH $a.ADE•Laal BlMtlay 66. UNpER I YEAR SC. UNDER 1 DAY 8. DATE OP BIRTH (Mo., pay. Y[)
<br /> (Yea.) MOB, DAYS HOURS MINS,
<br /> Franklin, Nebraska 82 April2l, 1924
<br /> 7.SOCI0.LSECURIIYNUMBER Bs.PI-ACEDFDEATH
<br /> 508-18-8934 HOSPITAL: ~ Inpatlanl OrrtTt: ^ NuningHornaATD t~HOSgceFadGry
<br /> Bb. FACILITWNAME (II nvt Inslllulion, gire elrvat and number) ^ ERroupabent ^ DecedenCaHame
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<br />Saint Francis Medical Center
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<br /> ec.CITYORTpWNOFDEATW (IndudrZlpCoda) Sd.000NTYOPpEATH
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<br />Grand Island 68803
<br />Hall
<br />= OiAESIDENCESTATE 9D,000NTY AcC11YORTOYVN
<br /> Nebraska Hall Grand Island
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<br />r~ 8d STREETANDNUMSER Se. APT. NO 81.11PCODE eq- INSIDE CITY LIMITS
<br /> 504 W. 15th St. 68801 ~ Yes ^ ND
<br /> 10a. MARITAL STATUS AT TIME OF D:A7H ~ Maned ^ Never Marned 1pb. NAME OFSPOUSE (rirsl. Middle, Lasl, SuRlx) Ilw!h, give maldenneme.
<br />
<br /> Q Maned, but aepanled ^ Wldtlwed ^ Droned Q Uliandwn
<br />~ Cart Au ust Luebbe
<br /> It. FATHER'S•NAME IFlnl, MIddL. Lett, 9ulllr) 12. MOTHER'S-NAME (Flat. Middle, Malden Surname)
<br />F Orvtl F Reams Jessie L KRIsD
<br /> 17. EYER IN U.S. ARMED FOACES7 GNa daleaplaervlq ilyet. 1aa INFpRHANTNAME t4b. RELATIONSHIP TO DECEDENT
<br /> (ves, no, nruna.) No Carl Au ust Luebbe Husband
<br /> 18.HETHOODFDISPO$ITION~ 1raEMEV1LMERSIG 16D-I1CEN5EN0. IBC. DATE (Md.,Day,Yr.)
<br /> ~ &xlal [] Donakpn r`
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<br />Au ust 14, 2006
<br /> ^Cnmadon ©Entompment I ~ METERY,CRENATORY ROTHERLD ION CITYrTOWN STATE
<br /> [,]Removal ^ Omar (Speefry)
<br /> Grand Island City Cemetery Grand Island Nebraska
<br /> iyiFUNERALHOMENAMEANpMAlLIHOADDAE55 (Sheet.CiryorTown,$Ie1e
<br />~ 176.ZIpCoda
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island,
<br />ettraska 688D1
<br /> C ATH (See nstructlone en exemplee
<br /> 18 PART I. Enla the Maln olevents••dlsNaea.lplgdee, Dr wmpllfm8one--that drlClly caused 8w dealt DO NOT Mler temanal evenl7 aUC7197 CirdleC aRea1, 1 APPROXIMATE INTERVAL
<br /> nsplralory arnH. dr vanptcWar Sbdllatlon without shtlwlnp the eL0logy. DO NOT ABBREVIATE. Enter only one Cauca on a IVIe. Atltl adtlltlpnel Mnet II necessary. I
<br /> IMMEDIATECAUSF: I onsUlodaalh
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<br />(dlHNSa Nllry 7tH Mebrled (o)
<br /> AeewrlbnwAinghdesh) DUE Tp,ORASACONSEOUENCEOF: I anaWlodaatlf
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<br /> 18. PA RT IL DTHER SIGNIFlCANi CONDITIONS•CoMtkonf corudbutlnq to 81e death Md ntlt nrwbnq In the urderrylnq cause yven m FART 1. 1 S!. WA$ MEDICAL EXAMINER
<br /> N ~~ ORCORONERCpNTAC7EDT
<br /> ^ YES NO
<br />~ 20.IP-EMALE: 21a.MANNEROFpEATH 21b.IFTRAN5PORTATIONINJURY 21C,WASANAUTDPSYPERrORMEp'I
<br /> ~NdlprepnerdwllnlnpeslyNr ~NalurH ^Hom~ade ^Dnvalpperabr
<br />^YES
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<br /> ^ pregnant al Gme tll dulh ^ ACCidenl^ Pendnq hveatlpadon
<br />^Pasw+per
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<br />$ ^ kdlpngnenl,putpngnantMlhln/2dayeoldeatn
<br />^ SUdde ^ comd not w ddnmrnad ^PedHldan 21d.WEREAUTOP$YFlNDINGSAYNUI)LE7O
<br />$ ^ Not prepnard, bulprcgrrme]daye lolyeu 6elorednh ^OMr(Speptyl OpMPLEIE CAl1sE OF pEATH7
<br /> ^ Unknown II pregnant within the past year ^YES ^ ND
<br />~ 22a- pATEOF INJVAY IMe„ Oey, Yr.) 22D.7IME OF INJURY 22e. PLACE OF INJURY-Alhonr. farm, meet, lottery. dlM1ce 6ulldlrq, cpnafrucdon slu, qe. (epeciryl
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<br />22d.INJURYATWORK-
<br />22s,DESCRIBEHOWINJURY000URREp
<br /> © YES ^ ND
<br /> 22f.LOCATIONOFINJURY-STREETANUMBER,APLNO. CITYlTOWN $171TE ZIPCpDE
<br /> 29a,DATEOFDEATH(MUDy,SC1 11 2 ()6
<br />~w Pea,pATESIGHED(MO.,pay,Yc) 2e6.TIMEOFOEATH
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<br />~~ 2$b.DATESI('NEp(Me.pey,Yr.1 29e.TMEOFDEATH ~
<br />2te.PRONOUNCEDDEAD(Ma..DegVr.) 2adTIMEPRt]NpUNCEDDEAO
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<br />1:35 p.m
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<br />duelo the ceueep) elated. (Slgnatun and Tlbe i ~ o O ~ the bme, date and place and due Id Cie eauayq Hand. ($rgnatuN and Tipe 1 ~
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<br /> 26.DIDTOaACCOUSEGON7RIBl17ETOTHEDEA7H7 28a.HASORGANDRA$BUEDONATfONBEEHCON510ERED'7 II6b.WA5CON5ENTGRANTED'r
<br /> ^ YEB NO ^PiK)BABLY ^ UNKNOWN ^YES ~D Nol AppllwNelf 24e le N0 ^YES NO
<br /> 27. NAME. TITLEANpADDRESSOFCERTIFIEfl (PHYSICIAN,CORONER'S PHYSICIAN ORCOUN7YA771gHNEY1 (rypeorPnnq
<br /> Anne K. MorESe,M.D.,729 N.Cust:er Ave., Grand Island Nebraska 6$St?1
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<br />p 2B7 REGISTRAR'S SIGNATURE 286.DAT! FILED By tl(1,IST~IA~(M~~„yr)
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