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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HLM1A/1y SERVICES, IT CERTIFIES
<br />THE BELOW TO 8E A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASIf~4'DEPARThfEIUT aF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR [/1TACr F2'E~"ORdS: ~ '
<br />DATE OF ISSUANCE ~~~~~ ~ ~~ ~+~ ,
<br />r STANLEY S. C-flp~r=R'
<br />JAN ~ ~ ZOQ9 c ~~aa J ASS~STAgI~ STATE REIISTRAR
<br />LINCOLN, NEBRASKA 2 O ~ Q O 5 O V rj aLIMAN SERV ~E~ EALTH A(VD •
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<br />STATE OF NE6RASKA- DEPARTMENT OF HEALTH ANb HUMAN SERVIGES FINANCE AND 3UPPOFlf ~ !' ~ ~~
<br />CERTIFICATE OF I7FATH ' ~`Q ~ '~l'1 C7 .!t
<br /> 1. bECEpENT'S-NAME (First, Middle, Lest, T Sufnx) 2. SEx 3. DATEOFOEATH (Mo.,Day,Yr.)
<br /> Melvin Geor a Emde Male December 26, 2008
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTW 5s. ApE•Laet Birthday 5b. UNpER 1 YEAR 5c. UNDER 1 pAY 8. DATE OF BIRTH (Mo., Dey, Yr.)
<br />
<br />Elgin, Nebraska (Yrs.)
<br />85 MOS. DAYS HOURS MINS.
<br />January 31, 1923
<br /> 7. SOCIAL SECURITY NUMBER Ba. PLACE OF bEATH
<br /> _ SO8-16-003.5 HOgp1T9L: ^ Inpatient ~; ^ Nureing HomelLTC ^Hpspice Faculty
<br /> _~
<br />8b. FACILITY•NAME (If not institution, glue street end number)
<br /> ^ ER/Outpatient ~ Decedent's Home
<br /> Home: 2716 W. Koenig
<br /> ^ DOA ^ Other (Specify)
<br /> 6c. CITY qR TOWN OF DEATH pnclude Zlp Code) 8d. COUNTY OF DEATH
<br /> Grand Island 6$803 Hall
<br /> 9a. RESIDENCE~STATE 96. COUNTY 9c. CITY OR TOWN
<br /> Nebraska Hall Grand Island
<br /> 9d. S7REETANDNUMBER 9e. APT. NO 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 2716 W. Koenig
<br />68803 I~ YES ^ No
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<br />10a. MARITAL STATUS AT TIME OF DEATH ](J Married ^ Never Married 106. NAME OF SPOUSE (First, Middle, La86 Suffix) If wife, glue maiden name.
<br /> ^Marrled,butaepereted ^Wldowed ^Dlvorced ^Unknown 1~Oi5 Bentley
<br /> 11. FATHER'S•NAME (Flrat, Middle, Laet, SufflX) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br /> Otto M. Emde Zella M. Condon
<br /> 13. VEVER IN V.S.ARMEbFDRCE57Glvedatesolserviceit es.
<br />~/25/1944 12/7/1945
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<br />i 14a.INFORMANT•NAME 14b.RELATI0N5HIPTODECEDENT
<br /> (YeS,
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<br />°nk Loi_s_
<br />Emde Wife
<br /> 15. METHOD OF DISPOSITION _
<br />18a.
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<br />B~MER-SIGNA7UR ~y ~ 186. LICENSE N0. ~? 18c. DATE (M°., Dey, Yr. )
<br /> ~jB°nal o°°naden (
<br />.
<br />v~'~Q /G~ _ ~$ December ~1 2008
<br /> ^Cremation ^Entombmem 18d.CEMETERY, EMATORVORO7HE OCATIDN CITY/TOWN STATE
<br />-; ^Ramoval ~.IOther(5peclfy)
<br />^~ WestlaWn Memorial Park Cemetery Grand Island, Nebraska
<br />- 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty orTown, State) 17b. Zip Cade
<br /> Apfel Funeral Home, 1123 West Second, Grand Island, NE 68801
<br />_ tE. PART I, Enter the ghein vt evente•-dlaeaeae, Injuries, or campllcatlone--that directly caused the death. DO NqT enter terminal events such as cardiac arrest, APPROXIMATE INTEFlVAL
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<br />~ respiratory arrest, pr ventricular Ilbdlletidn without showing the e11°Idgy. b0 NOT ABBREVIATE. Enter only one cause on a Ilne. Add additional Imes II necessary. I
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<br />~. IMMEDIATE CAUSE: I
<br />dnset tv death
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<br />~ IMMEDIATE CAUSE(Final (e) I `~~Q t ~_
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<br />.z: , dleeeeewcondklanreaulting DUE T0, OR A5 ACONSEQUENCE OF: -
<br />I onset tc death
<br />In death)
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<br />Saquentlallyllal cendltlone, if (6)
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<br />any, leadingfotheceuaellated DUE 70,oRASACONSEQUENCEOF: ~ '- •
<br />I on to death
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<br /> EnbriheUNDERLYINOCAl1SE I
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<br />DUE TO, OR AS A CONSEQUENCE OR - I Onset to death
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<br /> 18. PART IL OTHER SIGNIFICANT CONDITIONS-Cdnditiona contrlbuting t° the death but not resulting In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
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<br />CORONER CONTACTED?
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<br /> 20. IF FEMALE: 21a.
<br />NEROFDEATH 216.1
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<br />TATIDNINJURY 21c.WASANAUTOPSYPERFORMED?
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<br />U Nol pregnant within past year Natural ^ Hvmlclde p slot ,Iy
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<br />u YES ~C] ND
<br />U Pregnant at time df death ^ Accldent^ Pending Inve9hgehon 9
<br /> ^ Not pregnant, but pregnant within 42 days of death ^ Pedestrian 21d. WEREAUTOPSY FINDINGS AVAILABLETO
<br />^ Suicide ^ Could not 6e determined
<br /> ^N°lpregnant, but pregnant 43 days fol yeerbefore death ^Other (Specify) COMPLETE CAUSE OFDEA7H7
<br />~.. ^ Unknownifpregnantwlthlnthep~elyear ^ YES ~NO
<br />- 22a. DATE qF INJURY (Mo., bay; Yr.) 226. TIME OF INJURY 22c. PLACE OF INJURY•At home, term, street, factory, ofllce building, constructlOn alts, etc. (Specify)
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<br />" 22d.INJURYAT WDRK7 22e. DESCRIBE HOW INJURY OCCURRED
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<br />a`,, , ^ YES ^ NO
<br /> 221. LOCATION OF INJURY • STREET 8 NUMBER, APT. NO. CITY/TDWN T uTyJE ~ ZIP CODE
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<br /> 23a. DATE OF EATH (M ., De Yr.) Z } 24a. DATE SIGNED (Mp., bay, Yr.) 24b. TIME qF DEATH
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<br /> y 23b. DATE 51 NED (M ., D.) 2 TIME ATH ~ ~ ~ 24c. PRONOUNCED DEAD Mo., Day, Yr.) 24d. TIME PRONOUNCEb DEAD
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<br />. ~ 23d. To the best pf my kn d e, d ath occurred et the time, data a place ~` w ~ ~ 24e. On Iha basis pf examination end/or Invesugelipn, in my opinion death occurred at
<br />$ ~ and due tv the cau e( to . i lure and Title • _/,
<br />I'J1 ~ ~ U the time, date end place and due to the cause(s) stated. (Signature and Title) •
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<br /> 25. pIDTOBACCO USE CONTRIBUTET07HE DEA 28e. HAS ORGAN OR TISSUE DONATION BEEN CON51DER6b7 286. WAS CONSENT GRANTED?
<br />I ~ ^ YES ^ NO ^ PROBABLY UNKNOWN ^ YE5 NO Not Applicable If 26e is NO ^ YES ^ NO
<br /> 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY pRNEY) (Type or Print)
<br />L,~': Travis Hageman M.D. 729 N. Custer Ave., Grand island, NE, 68803
<br /> 28a. REGISTRAR'5SIGNATURE 28b, DATE FILEb 8Y REGISTRAR (Mo., Day, Yr.)
<br /> ,( ~. JAN Z 2009
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<br />HHS-61 11/03 (55081)
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