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WHEN THtiS COPYCAW�ES Tl� RA/SED SEAL OF THE NEARA3KA HEALTH AAID /dUMAN SERVICES
<br />SY5TEl1� !T CERI7FIE5 THE BELOW TO BE A TI7UE COPY OF THE ORIfilNA1 RECOR4] aN F/LE YV/TH
<br />THE NEBRASKA HEALTH AND HUMAN SER1/ICES SYSTEM, NITAI. 31'/1'FISTIGS�I�I�A�N�H !S
<br />THE LEQAL DEPOSITORY FOR V/TAL R�CORDS - " --
<br />DATE OF lSSfJANCE �' � " -
<br />� S. CDOPE� _
<br />11 /13/2003 2 Q 1 Q Q'� "� 3 g �ssrsranrrs���c�r�rr�-=
<br />LINCOLN, NEBIt,45KA H�Al.TM AND I�61A�9N SERVICE3�`S�'ST�JLI- _
<br />.:, �, _ �_ �:
<br />STATE OF NESItASKA- DEPARTMENT OF HEAT.TH AND HUM?,N SE�YI�6,$�AI� S'C]�qRT
<br />��. STATTS��S - = - =_ � 0 3 �. � � 7 6
<br />CERTIFICATE OF DEATH J ' - ""�
<br />1, DECEDENT-NAME FIRST � MID�LE � LAST 2. SEX 3. DATEpFDEq7H /Month.Oay.Year/ .
<br />Wendle Henry Hagmann Male November 7,2.p93
<br />4. CITV ANO STATE OF BIRiH /P rrof in US.A.. name cquptryl 5a. AGE - LaBt Birthdey UNDER 1 VEAR UNpER 1 pAV 6. DATE OF 61RTW /MOnth. Oey. Year)
<br />- St. P1u1. Nebra �'''g� 82 sa.Mos. i oavs S�.HO�AS M�NS. April L1, 1921
<br />� 7, SOCIAL SECUATIV NIIMBER
<br />� 506-18-4291
<br />i B6. FACILITV - Name
<br />i St. �'rancis Medical Center
<br />Bc, CITy TOWN OF 40CATIqN pF pEATH� � �
<br />� S'
<br />Nebraska Ha11
<br />10. FACE •(e.g., White, BlaCk. Ameritan Intllan, 11. ANCEST
<br />e1c,If5peciy� (Specdvl
<br />White
<br />14a, USUALpCGUPq710N /GivBklr�dwOrkdOn9dwirlgmosf
<br />� olwarkinglilg,evanilreliredl
<br />� Auto Technician
<br />J
<br />: 78. FATHER • NAME FIRST MID
<br />Henry
<br />� � Ba PLACE OF �EATH �
<br />� HOSPITAL � Inpalient OTHER � Nursmg Home
<br />T � ER Outpatient � Re6idence
<br />❑ OOA ❑ O�he� lSpecdVl
<br />Bd. INSIDE CITV LIMiTS Be. COUNTV OF DEA7H �
<br />Yes t�o . I
<br />9 G. GTY,TOWh10FlACAT10N
<br />Grand Is�and
<br />�e.g., Italien. MeKican, ¢erman, e1t) 12. � MARRIE
<br />Ame r ic an NEYER
<br />MAR I
<br />1A6, KIN� QF BUSINES51Npl1STqV
<br />Automobile
<br />� LA5T 77. MOTHER
<br />Hagmann
<br />- 18. WAS �ECEASED EVER IN U.S. ARME� FORGE$?
<br />I�as, no. or unk.� (II yes. giye war dnp patgs of�6arvlCe6)
<br />Yes 9 2 42 to 12 2 45
<br />19b.INFORMANT MAILIN�ADDfiE55 ISTREETQR
<br />142$ N. La�a ette rand I
<br />2p MBALMER - 516NATl1RE & LIGEN3E N0. �
<br />�.Lc�c ��/ 43
<br />22a. FuNpIiA� HOME • NAME
<br />Livin stan-Sondermann F. H.•
<br />�, FUNERAL HOME qOpRESS ISTREET OR R.F.D. NQ.. CITV OR Y
<br />19a. INFORMANT - NAME
<br />Freda Ha mann
<br />�--�- . .....
<br />/ OR T04VN. STATE. ZIP) ,
<br />21b. DATE
<br />21c,CEMETERV OR
<br />�9uriel �Ramoval NQ�V. $� 2��3 Westlawn Cremato
<br />21d. CEMETERY OR CREMATpRY LOCA710N CITy OR TOWN
<br />� Cremauon ❑ oo�euo� Grand Isl.and
<br />601 N. Webb Rd. Grand Island, NE b8803
<br />23. IMMEDIATE CAl15E . (ENTEq ONLY ONE CAl15E PER LINE FOR la�. (bl. ANp (c�) I Interval between onsat antl deatn
<br />,�PART ���__[�, � / � t � I ///� �� .
<br />� I (dl `'T�.rr � � �` � �W'C � ,- V,. � ��+� T'c i '�-t • . � � '" �'` ,S
<br />� �UE T0, OR AS A CONSEOUENCE OF " � � I Interval 6etween onset antl tleatn
<br />� n,n I
<br />r Ib� Y 6tira( '�.,1,,.� � � �
<br />_� pUE TO.OR AS A GONSEOl1ENC� qF' � � � ���� �� I Interval 6etwean onsel and death
<br />U.� r��,,. �
<br />��i �f'�,� �� f�.���t>..� . � Gf.��(J
<br />�
<br />OTHER SIGNIFICANT CONDITIONS • Conditions conM6uung ro Ihe deam but npt r9lated PART III IF FEMALE. WA$ YHERE A 24 Al1TOP5Y 25. WAS CASE REFERRED TO MEDICAL
<br />PAIR7 PREGNANCY IN THE PAST 3 MONTM57 �.. x EXAMINE{7 OF CORONER?
<br />� (Ages 10-54� V06 No Yes NO Vas No
<br />28d. �6. bAYE OF INJURY lMa. Oey. Yc) 28c. HOl1R OF INJURV 26d: OESCFNBE HOW IN.:.�RV OCCUF1f7E�
<br />� ACC�dBnt � Undelermined � �
<br />� 5uiCiAe � Pending 26e. INJURY AT WORK 261. PLAC�O�P.I�JURV %At hom�, farm. gtreet. faCtory 26g. LOCATION STREET OR R.FD. NO. CITV OR TOWN
<br />❑ ❑ ❑ oRice mdm etc. SpaG�y� ,
<br />Haniclde InvesUgetion yy No
<br />� 27a. DATE OF pFATH /Mo.. Ddy. Yr./ 28a. DATE $IGNEp /MO., bay. YrJ 28b TIME OF tlEATH
<br />k //' 7 �" � � � �
<br />1�� 27b. �ATE 51GNE� /Mo.. Day. Yc/ 27p.� TIME OF pEqTH � i� 28c� PRONOUNCED �EA� (Mp..77ay, Yc/ 28d. PRONOUNCE� OEAD /Hourl
<br />_,��,o � 1 ��7��3 a' L?Ca:3d M ����
<br />27d. To tqe 6ast ol my knowledge, dealh occurrcd st Ihe time, data and place and due lo the °� g 29e. On iha besis of examination antl�or InveStigatlon, in my opinion death cecurted at
<br />}~ �causelsl &tatpd. � � j� n � . � ihe timB, date antl place and due to ihe cquse�s) stated. �
<br />� �� �
<br />(Si nature and TNIa (Si naWre and TNIg ►
<br />29, DI� TOBACCO USE CONYq16UT�Fr 7HE �EATH7 � 30.g HAS ORGAN OR TISSl1E DqNATION 9EEN C�NSIDERE�? 30.6 WAS CONSEN7 GRANTE�?
<br />� � YES Ixl NO � UNKNOWN � •� VES �/V�' NO - � .� VES I/\ I NO
<br />Y'��� ,�- �� ��
<br />37. NqME A N n annpcca �p_ p�pT�FIER �PtiVSICIAN, COAONER�S PHYSICIAN OR CQl1NTV qT70RNEVl IrY�e w PnnU
<br />Jeffrey King 729 N, Cust r Grand Is and, NE 68803
<br />32a. REGISTRAR , / 32b. OATE FlLED BY REGISTRAR (hb.. Day. Yr.l
<br />�e"�� ��.... ..._..........._�-- -..:--�- �-- �
<br />9d. STREET qND NUMBER /Inc/udMgZ/p COdB/ 9e. INSIDE CITY 41MI75
<br />1428 N, Lafa ette 6$803 �es � No ❑
<br />❑ WIDOWED 13. NAME OF SPOUSE lIlwile. givemalden name)
<br />oivoaceo �rEC�a laau �ass
<br />15. E�l1CATION (Spetify Only nighebt grede complated)
<br />� Ele�n�n�ry or 5�0� I�O�t2) �� � COII9gQ 11-0 pr 5-1
<br />1 h d
<br />FIR57 MIDDLE MAIpEN SURNAME
<br />Goldia Davis
<br />STATE
<br />M
<br />�►�rx::i ►1 11
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